USAIDKENYA AFYA TIMIZA

YEAR 3: QUARTER 3 PROGRESS REPORT

A community health volunteer counselling a mother on routine immunization for her child during a mobile outreach in a hard to reach area.

JULY 2019 This publication was produced for review by the United States Agency for International Development. It was prepared by Amref Health Africa in Kenya

USAID KENYA (AFYA TIMIZA) FY 2019 Q3 PROGRESS REPORT

1 April 2019 – 30 June 2019

Award No: AID-615-A-16-00009

Prepared for Ruth Tiampati, AOR United States Agency for International Development/Kenya C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya

Prepared by

Amref Health Africa in Kenya Wilson Airport, Lang’ata Road P.O Box 30125, GPO 00100 Nairobi, Kenya

DISCLAIMER

The authors’ views expressed in this report do not necessarily reflect the views of the United States Agency for International Development or the United States Government

TABLE OF CONTENTS ACRONYMS AND ABBREVIATIONS ...... V EXECUTIVE SUMMARY ...... VI II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 10 III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT)...... 71 IV. CONSTRAINTS AND OPPORTUNITIES ...... 72 V. PERFORMANCE MONITORING ...... 72 VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 75 VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 76 IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 76 X. JOURNEY TO SELF RELIANCE (J2SR) ...... 76 XI. SUSTAINABILITY AND EXIT STRATEGY ...... 77 XII. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE) ...... 77 XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 78 XIV. FINANCIAL INFORMATION ...... 78 XV. ACTIVITY ADMINISTRATION ...... 81 XVI. INFORMATION FOR ANNUAL REPORTS ONLY ...... 81 XVII. GPS INFORMATION ...... 81 XVIII. SUCCESS STORY GUIDELINES...... 82 ANNEXES & ATTACHMENTS ...... 86

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LIST OF TABLES Table 1: Key achievements of AFYA TIMIZA during the period under review ...... vii Table 2: Distribution of antenatal clients served by approach in Turkana County ...... 12 Table 3: Distribution of ANC clients served by approach in Samburu County ...... 14 Table 4: Number and percent of neonatal outcomes ...... 22 Table 5: Post Abortion care services Turkana County ...... 24 Table 6: Post Abortion care services Samburu County ...... 25 Table 7: Number mothers provided with post-natal care services in Turkana County ...... 26 Table 8: Number mothers provided with post-natal care services in Samburu County ...... 28 Table 9: Number of children immunized ...... 29 Table 10: Number of children reached at various service delivery points in Turkana County ...... 31 Table 11: Top ten causes of morbidity for under five children in Turkana Apr - Jun 2019 ...... 33 Table 12: Top ten causes of morbidity for under five children in Samburu Apr - Jun 2019 ...... 34 Table 13: Uptake of family planning commodities among women of reproductive age (Apr– June 2019) ...... 35 Table 14: Uptake of FP commodities in CCC clinics (Apr-Jun 2019) ...... 36 Table 15: Couple years of protection in Turkana and Samburu ...... 44 Table 16: Uptake of Iron and Folate Supplementation by Pregnant Women (April - June 2019) ...... 46 Table 17: Number of Children Dewormed in Turkana ...... 47 Table 18: Vitamin A Coverage and Uptake ...... 51 Table 19: Progress on triggered villages towards ODF status in Turkana South...... 53 Table 20: Number of Health Workers Trained In Turkana County ...... 58 Table 21: Number of Health Workers Trained In Samburu County ...... 59 Table 22: Survivors attended to April- June 2019 quarter and offered post GBV care in Samburu and Turkana Counties-Source: KHIS 2019 ...... 69 Table 23: Medicolegal Linkage and outcomes Jan- April 2019 Maralal County Referral Hospital and Police Station ...... 69 Table 24: Number sensitized on Gender Integration and SGBV per cadre ...... 70 Table 25: Data use Calendar with respective mapped decision Turkana South ...... 73 Table 26: Environmental Threats and Mitigation Measures by the Project during the Quarter ...... 75

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LIST OF FIGURES Figure 1: Antenatal care achievements against expected targets in Turkana and Samburu counties ...... 11 Figure 2: Proportion of pregnant women attending 4 ANC visits according to focused antenatal care schedule in Turkana County (Source: KHIS) ...... 11 Figure 3: Integrated outreach session in Turkana South ...... 12 Figure 4: Pregnancy distribution among adults and adolescents in Turkana Sub-counties ...... 13 Figure 5: Proportion of pregnant women attending 4 antenatal care visits according to focused antenatal schedule in Samburu County (Source: KHIS) ...... 14 Figure 6: Pregnancy distribution among adults and adolescents in Samburu Sub-counties ...... 15 Figure 7: Number of deliveries by a skilled birth attendant ...... 16 Figure 8: Distribution of births by type of delivery ...... 16 Figure 9: Delivery by skilled birth attendant coverage in Turkana County (Source: KHIS) ...... 17 Figure 10: Delivery by skilled birth attendant coverage in Samburu County (Source: KHIS) ...... 18 Figure 11: OJT on utilization of new baby warmer machine at Ndonyo Wasin Dispensary ...... 19 Figure 12: OJT on documentation at Archers Post HC ...... 19 Figure 13: TA through WhatsApp ...... 20 Figure 14: Distribution of maternal complications ...... 20 Figure 15: Follow up of a baby discharged from KMC at the MCH department ...... 23 Figure 16: KMC at Maternity Unit in SCRH ...... 23 Figure 17: Postnatal care attendance coverage in Turkana County (Source: KHIS) ...... 27 Figure 18: Postnatal care attendance coverage in Samburu County (Source: KHIS ...... 29 Figure 19: Proportion of children under one year who are fully immunized in Turkana County (Source: KHIS) ...... 30 Figure 20: Proportion of children under one year who are fully immunized in Samburu County (Source: KHIS) ...... 32 Figure 21: Clients receiving services in a Facility Based Outreach at Amayia community ...... 37 Figure 22: CME on integration of FP to HIV services in Wamba Health Centre ...... 37 Figure 23: Morans receiving counselling on FP/RMNCAH from a HCW during the outreaches in one of the sites in the hard to reach areas...... 38 Figure 24: Family planning method mix ...... 38 Figure 25: Family planning method mix in Turkana County ...... 39 Figure 26: Trends in family planning method mix in Turkana ...... 39 Figure 27: Sample of Commodity update using WhatsApp platform ...... 40 Figure 28: Demonstration box in Ngilai dispensary ...... 40 Figure 29: Family planning method mix in Samburu ...... 41 Figure 30: Uptake of family planning method among adolescent and youth in Turkana County ...... 42 Figure 31: Sirata Day Mixed Secondary School issued with Sanitary towels courtesy CEC Gender and Samburu Girls Foundation ...... 43 Figure 32: Uptake of family planning method among adolescent and youth in Samburu County ...... 43 Figure 33: Family planning commodity reporting rate trends by Sub-County ...... 45 Figure 34: Mothers listening to Digisomo messages on IFAS during MtMSG monthly meeting ...... 47 Figure 35: Number and Proportion of New CWC Children Exclusively Breastfed ...... 48 Figure 36: MUAC Screening Results among Children Aged 6 – 59 Months at CWC ...... 49 Figure 37: A group of MtMSG members venturing into food production through use of DTCs to enhance dietary diversity as well as generate income from sale of extra produce ...... 50 Figure 38: Sunken and vertical vegetable gardens at household level ...... 51 Figure 39: Food preparation demonstration sessions ...... 51 Figure 40: Vitamin A supplementation by CHVs at an ECD center ...... 52 Figure 41 Training session at Kaikor Sub-County Hospital ...... 55 Figure 42: Progress on Implementation of AFYA Timiza Mentorship and Coaching Program...... 60 Figure 43 Sensitization of caregivers’ session at Kaitese in Loima Sub County ...... 61 Figure 44: Session of traditional leader – Emurons engagement at Lochwaa ...... 61 Figure 45: CHVs pause for a photo after completing the training on Digisomo ...... 62 Figure 46: Feedback meetings in Swari and Lorubae ...... 62 Figure 47: Digisomo beneficiaries (Sept 2018- Apr 2019)...... 63 Figure 48: AFYA TIMIZA Officer presenting during the County QRM in Lokichar...... 63 Figure 49: Kanaodon CU Adolescent & Youths community group leaders planning meeting held outside one of the churches in Kanaodon ...... 64 Figure 50: A & Y on gallery walk on Mainyotto messages and materials ...... 64

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Figure 51: A & Y mentors learning how to use Digisomo talking books ...... 64 Figure 52: Binti Shujaas at Kang'akipur Health Centre ...... 65 Figure 53: CEC Gender and Youth mentoring Sirata Secondary School students during menstrual hygiene day celebrations ...... 65 Figure 54: Data collection during social intelligence reporting conducted at Lkiloriti Dispensary ...... 66 Figure 55: Sensitization of Islamic women on cervical cancer ...... 67 Figure 56: Menstrual hygiene day celebration in Kisima and Sirata Secondary Schools ...... 68 Figure 57: Stakeholders’ forum during Gender Policies review forum in Samburu County ...... 68 Figure 58: Gender integration and Clinical management of SGBV in Samburu County ...... 68 Figure 59: International Day of the African Child in Turkana County ...... 70 Figure 60: Deputy Governor Samburu County during gender policy and Anti-beading policy stakeholder’s forum ...... 71 Figure 61: FP/RMNCAH scorecards displayed ...... 73 Figure 62: CHEW and facility in-charge reviewing the dashboard at Ndonyo Wasin Disp Samburu East ...... 73 Figure 63: Nurse at Nakabosan dispensary validating data on teenage pregnancies with A&Y officer from Afya Timiza during data review meeting ...... 74

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ACRONYMS AND ABBREVIATIONS

AMTSL Active Management of Third Stage of Health Facility Management Committee Labor HFMC ANC Antenatal Care HIV Human Immunodeficiency Virus APH Ante Partum Hemorrhage HIS Health Information System APHIA AIDS, Population and Health Integrated HIV HIV Testing Services Assistance HTS APR Annual Progress Report HPN Health, Population and Nutrition A & Y Adolescents and Youth IHRIS Integrated Human Resources Information System BEMONC Basic Emergency Obstetric and Neonatal ICCM Integrated Community Case Management Care BFCI Baby Friendly Community Initiative IMCI Integrated Management of Childhood Illnesses BFHI Baby-Friendly Hospital Initiative IPC Infection Prevention Control C4C Counselling For Continuation IUCD Intrauterine Contraceptive Device CEMONC Comprehensive Emergency Obstetric and IYMCN Infant Young Child Nutrition Newborn Care CDOH County Department of Health MCUL Master Community Unit List CHAT Community Health Africa Trust MIYCN Maternal Infant Young Child Nutrition CHEW Community Health Extension Worker MNCH Maternal Newborn and Child Health CHMT County Health Management Team MOH Ministry of Health CHRIO County Health Records Information MPDSR Maternal Perinatal Death Surveillance & Officer Response CHV Community Health Volunteer NACS Nutrition Assessment, Counseling, and Support CHW Community Health Worker NHIF National Health Insurance Fund CHU Community Health Unit NHP Nutrition and Health Program CHLDP County Health Leadership and NICRA Negotiated Indirect Cost Rate Agreements Development Plan CHSIP County Health Strategic Investment Plan OCA Organizational Capacity Assessments CICA County Institutional Capacity Assessment OJT On-Job-Training CME Continuous Medical Education OPV Oral Polio Vaccine CNO County Nutrition Officer ORS Oral Rehydration Salts CNTF County Nutrition Technical Forum ORT Oral Rehydration Therapy COG Council of Governor PAC Post-Abortion Care CORP Community Owned Resource Person PCV Pneumococcal Conjugate Vaccine CS Caesarean Section PLGHA Protecting Life in Global Assistance CU Community Unit PMBR Planning Budgeting Monitoring and Reporting CWC Child Welfare Clinic PNC Post-Natal Care CYP Couple Years of Protection PPE Personal Protection Equipment DFH Division of Family Health PPH Postpartum Hemorrhage DHIS District Health Information System PREG Partnership for Resilience and Economic. Growth DPT Diphtheria, Tetanus, and Pertussis PSC Project Steering Committee DQA Data Quality Assurance PSK Population Services Kenya ECD Early Childhood Development RCEA Reformed Church of East Africa EMONC Emergency Obstetric and Neonatal Care RDQA Routine Data Quality Audit EPI Extended Program for Immunization RH Reproductive Health ESRC Ethics & Scientific Review Committee RMCAH Reproductive Maternal Newborn Child and Adolescent Health F2FSG Father to Father Support Group RTKs Rapid Testing Kits FANC Focus on Antenatal Care RTIN Royal Tropical Institute of the Netherlands FCDRR Facility Consumption Data Report and SOP Standard Operation Procedure Request FP Family Planning TAC Technical Advisory Committee FY Financial Year SGBV Sexual Gender Based Violence GBV Gender Based Violence STI Sexually Transmitted Diseases FIC Fully Immunized Children TBA Traditional Birth Attendant HC3 Healthy Choice 3 TBS’C Traditional Birth Companions HCW Health Care Worker TNA Training Needs Assessment HES Household Economic Strengthening TOR Terms of Reference HF Health Facility TWG Technical Working Group HFMT Health Facility Management Teams YFS Youth Friendly Services

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EXECUTIVE SUMMARY

Qualitative Impact

This report covers Quarter 3 of year 3 of project implementation (April-June 2019) and describes the activities and achievements during the quarter, performance in all supported program areas and planned activities for the subsequent quarter.

To sustainably increase the availability and utilization of quality FP/RMNCAH and nutrition services at community and health facility, the project strengthened the capacity of the CHMTs, SCHMTs, HFMTs and Community level structures to coordinate, supervise and monitor health sector services in Turkana and Samburu Counties.

The project team in partnership with the CHMT and SCHMTs provided technical and financial support to 1,068 Community Health Volunteers (CHVs) in 50 Community units and Health Care Workers (HCWs) in 153 health facilities to provide quality FP/RMNCAH and nutrition services in Kibish, Loima and Turkana South sub-counties in Turkana County and Samburu Central and Samburu East sub-counties in Samburu County.

To remain on the self-reliance path and promote commitment in county health leadership, management and governance, AFYA TIMIZA engaged AMREF’s Institute for Capacity Development to train 28 health facility management committees (HFMCs) in Turkana County on corporate governance and understanding the budgeting and planning process. Moreover, 26 facility in-charges in Loima, Kibish and Turkana South Sub-Counties underwent similar training to build on their knowledge and skills for effective leadership, management and governance of resources and enhanced service delivery within a level two and three facilities.

To address lack of linkages between budgetary allocations and sector priorities identified during the health sector performance review, AFYA TIMIZA sensitized the County Department of Health (CDOH) in both counties on the need to implement major health systems reforms aimed at improving resource priority setting, planning and budgeting, including the involvement of communities in planning and budgeting decision‐making. To achieve this, the project supported the two CDOHs to develop County Health Sector Strategic and Investment Plans with clear priority objectives and targets that ensures a clear linkage between the strategic priority objectives identified in the sector strategic plan with the annual program based budgetary allocations within the CDOH.

Quantitative Impact

Table 1 below summarizes the key achievements of AFYA TIMIZA for the period under review. Further detailed description of the achievements are provided under Section III of the report.

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Table 1: Key achievements of AFYA TIMIZA for the period under review Achievements Quarterly Q3 % Progress Coverage Key Achievement Table Q3 Targets Achievement towards Q1 Q2 Q3 Totals APR Program # Indicator targets HL.9.1 Number of children under five (0-59 months) reached by nutrition 1 16563 9456 21267 47286 8591 248% 138% 90% specific interventions through USG Nutrition supported programs HL.9-1-a Number of children whose 2 parents/caretakers received behavior 2599 3575 2750 8924 3335 82% 67% 84% Nutrition change communication interventions HL. 9-1b Number of children under 3 five who received Vitamin A from 16563 9456 21267 47286 8591 248% 138% 83% Nutrition USG supported programs HL.9-1-c Number of children under five who received zinc 4 7772 6884 9043 23699 5656 160% 105% 41% supplementation during an episode of Nutrition diarrhea HL.9-2 Number of children under two (0-23 months) reached with 5 community-level nutrition 6567 6169 5329 18065 2878 185% 157% 176% interventions through USG- Nutrition supported programs HL.9-2 a Number of male children under two (0-23 months) reached 6 with community-level nutrition 3257 3084 2681 9022 1410 190% 160% 180% interventions through USG- Nutrition supported programs HL.9-2 b Number of female children under two (0-23 months) reached 7 with community-level nutrition 3310 3085 2648 9043 1468 180% 154% 173% interventions through USG- Nutrition supported programs HL. 9-3 Number of pregnant women reached by nutrition specific 8 2591 3575 2750 8916 3335 82% 67% 84% interventions through USG Nutrition supported programs HL.9-3-a Number of women receiving 9 iron and folic acid supplementation. 2591 3575 2750 8916 3335 82% 67% 84% Nutrition HL.9-3-b Number of women 10 receiving counseling on maternal 2591 3575 2750 8916 3335 82% 67% 84% Nutrition and/or child nutrition HL.9.4 Number of individuals receiving nutrition-related 11 0 292 29 321 75 39% 107% professional training through USG- Nutrition supported programs HL. CUST N1.0 Number of health 12 facilities with established capacity to 83 83 83 249 150 55% 55% Nutrition manage acute under nutrition HL. CUST MCH 4.0 Number of children who received DPT3 by 12 13 3624 4076 4427 12127 3827 116% 79% 67% Child months of age in USG-assisted Health programs Number of children who have received the third dose of 14 3499 3888 3069 10456 3827 80% 68% 58% Child pneumococcal conjugate vaccine by Health 12 months of age: Number of children under one year Child 15 who receive three doses of OPV 3007 3729 3819 10555 3827 100% 69% 59% Health excluding birth polio HL. CUST MCH 11.0 Number of Child 16 children under 1 fully immunized 2423 3377 3701 9501 3377 110% 70% 53% Health HL.6.3-2 Number of babies who received postnatal care within two 17 1467 1423 1829 4719 2433 75% 48% 25% Child days of childbirth in USG-supported Health programs HL.6.6-2 Number of cases of Child 18 childhood pneumonia treated in USG- 2828 2243 4165 9236 3868 108% 60% 87% Health assisted programs HL.6.6-1 Number of cases of child Child 19 diarrhea treated in USG-assisted 7772 6884 9043 23699 12783 71% 46% Health programs

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Achievements Quarterly Q3 % Progress Coverage Key Achievement Table Q3 Targets Achievement towards Q1 Q2 Q3 Totals APR Program # Indicator targets HL. CUST MCH 6.0 Number of USG- supported facilities that provide appropriate life-saving maternity care 20 19 29 37 85 42 88% 88% (This will be defined as seven signal Maternal functions for BEmONC and nine Health signal functions HL. CUST MCH 8.0 Number of community health workers (CHWs) 21 trained in maternal and/or newborn 0 315 94 409 50 188% 204% Maternal health and nutrition care through Health USG supported programs HL. CUST MCH 9.0 Number of health workers (HCWs) trained 22 in maternal and/or newborn health 0 19 0 19 29 0% 16% Maternal and nutrition care through USG Health supported programs HL. CUST MCH 7.0 Number of women who received at least 4 ANC 23 2457 2541 2822 7820 2862 99% 68% 41% Maternal visits during the latest pregnancy Health during a specified time period (year) HL.6.2-1 Number of women giving birth who received uterotonics in the 24 third stage of labor (or immediately 1779 1913 2265 5957 2433 93% 61% 74% Maternal after birth) through USG-supported Health programs HL. CUST MCH 10.0 Number of births in a given year attended by a 25 2413 2604 2644 7661 2433 109% 79% 40% Maternal skilled birth attendant (SBA) such as a Health doctor, nurse, or midwife HL. CUST MCH 17.0 Number of Maternal 26 adolescents (age 10-19) receiving 1439 1343 1637 4419 619 264% 178% Health ANC HL. CUST FP 15.0 Total number of health workers (HWs) trained in 27 0 56 0 56 56 0% 25% Family commodity management through Planning USG supported programs Total number of health workers Family 28 (HWs) trained in FP/RH through in- 0 46 0 46 56 0% 21% Planning service training HL.CUST FP 16.0 Percent of USG- assisted service delivery points (SDP) that experience a stock out at any 29 27% 42% 16% 42% 40% 40% 40% time during the reporting period of a Family contraceptive method that the SDP is Planning expected to provide CUST Numerator 33 52 20 49 49

CUST Denominator 124 124 124 124 124

9. 7.1-3 Average stock out rate of Family 30 contraceptive commodities at Family 17% 29% 2% 29% 6% 6% 6% Planning Planning (FP) service delivery points CUST Numerator 21 36 2 7 7

CUST Denominator 124 124 124 124 144

HL.7.1-1 Couple Years of Protection Family 31 (CYP) in USG supported programs 6648 8018 6674 21339 7310 91% 73% Planning % of service delivery sites providing Family 32 family planning (FP) counselling and/or 99% 98% 97% 97% 100% 97% 97% Planning services HL.7.1-2-a Numerator: Numerator 142 141 145 145 144

HL.7.1-2-b Denominator: Denominator 144 144 150 150 144

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Achievements Quarterly Q3 % Progress Coverage Key Achievement Table Q3 Targets Achievement towards Q1 Q2 Q3 Totals APR Program # Indicator targets Number of USG assisted community health workers (CHWs) providing 33 family planning (FP) information, 603 1039 1068 2710 419 255% 64% Family referrals, and/or services during the Planning year 10. HL.CUST FP 18.0 Number of Family 34 adolescents (10-19) receiving Family 568 640 542 1750 529 102% 83% Planning Planning services Number of people enrolling for health 35 insurance schemes 427 690 558 1675 325 172% 129% HSS Number of health workers including 36 community cadres supported with 603 1039 1068 2710 419 255% 64% HSS USG resources # of counties with AWPs priorities 37 (at least 2) reflected in the PBB for 2 2 2 2 2 100% 100% HSS health (reporting - annual) # of counties supported/facilitated to convene health sector working 38 2 2 2 2 2 100% 100% groups for MTEF process (reporting - HSS annual) # of counties with partner/stakeholder coordination 39 2 2 2 2 2 100% 100% (inter/intra) frameworks HSS established) # of public private partnerships 40 established and providing health 22 22 22 22 25 88% 88% HSS services ( reporting - bi annually)

Constraints and Opportunities

During the period under review, the insecurity situation experienced in some parts of Turkana South sub-county, continued to hinder access and utilization of services. Project technical teams were unable to effectively visit facilities to provide technical assistance and plan outreaches in hard to reach areas. Besides, the ravaging drought impacted negatively on the main source of livelihood for the nomadic population who entirely depend on the livestock for food and payment of medical expenses. Additionally, the project did not have obligated funds for one month in the quarter under review. As such, planned activities that required financial resources were frozen for a period of 31 days. Project technical staff were only able to implement cost neutral activities including collaborating with the MOH. Our collaboration with the county governments and other partners at county level was fruitful and will continue to be an area of focus for the project. We will continue with these collaborative actions and will leverage our efforts in a bid to ensure improved health outcomes for the communities.

Subsequent Quarter’s Work Plan Project implementation is planned to proceed in line with the approved work plan for the year. Key focus will be on the pending trainings, targeted mentorship and scalability of best practices and interventions that have continued to give the desired results. The next period will also focus on developing the 4th year work plan for the project.

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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

SUB-PURPOSE 1: INCREASED AVAILABILITY AND QUALITY DELIVERY OF FP/RMNCAH SERVICES

To sustainably increase availability and quality of FP/RMNCAH and nutrition services at community and health facility, the project strengthened institutional capacity of the CHMTs, SCHMTs, HFMTs and Community level structures to plan, coordinate and monitor health sector services in Turkana and Samburu Counties. The project team in partnership with the CHMT and SCHMTs supported 1,068 Community Health Volunteers (CHVs) in 50 Community units and Health Care Workers (HCWs) in 153 health facilities to provide quality FP/RMNCAH and nutrition services in Kibish, Loima and Turkana South sub-counties in Turkana County and Samburu Central and Samburu East sub-counties in Samburu County.

This sub-section provides a narrative description of the key achievements by service area attributable to the project support during the period under review. A: REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH A. 1 ANTENATAL CARE (ANC)

Antenatal care (ANC) from a skilled provider is important to monitor pregnancy and reduce the risk of morbidity and mortality for mother and baby during pregnancy and delivery. The quality of antenatal care is best monitored through the content of services received and the kind of information mothers are given during ANC visit. In the quarter under review, the project reached 5,262 pregnant women with antenatal care services during their first antenatal care visit in their recent pregnancy. This represents 108% achievement of the 4,861 estimated number of pregnant women (KNBS, 2009 population projections) during the reporting period.

In the same period under review, 2,822 pregnant women completed the recommended minimum of 4 focused antenatal care (FANC) visits to receive all the essential evidence based interventions that include identification and management of obstetric complications such as pre-eclampsia, tetanus toxoid immunization, and intermittent preventive treatment for malaria during pregnancy (IPTp), and identification and management of infections including HIV, syphilis and other sexually transmitted infections (STIs). This implies that 54% (2,822/5,262) of the pregnant women who attended the first time ANC managed to complete the recommended 4 ANC visits. Many of the potential life-saving opportunities continue to be missed by about one half of women during pregnancy. Overall, quarter 3 performance of the 4th ANC visit against the quarterly target was 98.6% (2,822/2,862), an improvement from the 88% reported in quarter 2. Among the 5,262 New ANC clients, 1,635 (29%) were adolescents aged 10-19 years.

Reflecting on the progress towards Annual Progress Report (APR) targets with regard to pregnant women completing 4 ANC visits, the project achieved 68% of the APR targets having

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so far reached 7,820 pregnant women with 4 ANC visits against an APR target of 11,448. The project performance for the quarter is as shown in Figure 1 below.

Antenatal Care Achievements Against Expected Targets in Samburu and Turkana

Figure 1: Antenatal care achievements against expected targets in Turkana and Samburu counties

The specific activities that contributed to the performance are highlighted as below by counties:

Turkana County:

During the period under review, 2,530 women attended 1st ANC, whereas 1,616 completed the recommended four focused antenatal care visits. This is an improvement from last quarter for 4th ANC where 1,507 completed 4th ANC in Turkana. This represents 111% achievement against the targets as shown in Figure 1 above.

At the sub county level, the proportion of pregnant women who attended ANC at least four times has been on an upward trend for the last one year except for the month of December where services were affected by the shortage of health care workers in most health facilities. As shown in Figure 2 below, Loima Sub County has been on upward trend in the last 2 quarters.

Proportion of Pregnant Women Attending 4th ANC According to Focused ANC Schedule in Turkana County

Figure 2: Proportion of pregnant women attending 4 ANC visits according to focused antenatal care schedule in Turkana County (Source: KHIS)

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To increase the uptake of ANC services in Turkana, the project team in collaboration with SCHMTs identified and listed 20 out of 46 health facilities with low transition of 4th ANC for targeted follow-up and further technical support. Through mentorship on FANC, the project strengthened capacity of 50 facility health care workers, 110 community health volunteers in quality provision of focused antenatal care services to pregnant mothers. Further, 20 health facilities received obstetric ultrasound machines from KEMSA through USAID support to enable early diagnosis of pregnancy and associated probable complications.

Turkana County Department of Health (CDOH) in collaboration with the project and other implementing partners such as International Rescue Committee (IRC), World Vision (WV) and Save the children supported the drought emergency integrated facility based outreaches in 50 sites in the hard –to- reach sites. Through these outreaches, 592 pregnant women received ANC services with 186 coming for the 1st time and 109 completing at least 4 ANC visits. The project also supported different integrated outreach models where comprehensive antenatal Figure 3: Integrated outreach session in Turkana care services were offered as part of services as seen South in Table 2 below.

Table 2: Distribution of antenatal clients served by approach in Turkana County ANC services Proportion of ANC Clients Proportion of ANC Clients served served at Health Facility at Facility based out-reaches

New ANC clients 2344 (93%) 186 (7%) ANC revisits 5124 (93%) 406 (7%) At least 4 ANC Visits 1503 (93%) 109 (7%)

During the quarter under review, the project supported 6 trained Quality improvement ToTs to conduct assessment on provision of quality package of care to the pregnant women. To enhance the skills of the service providers, ToTs mentored 50 (17 F: 33 M) health care workers on provision of quality focused antenatal care (FANC) with a focus on ANC profiling, HIV retesting, proper documentation and infection prevention. To build the capacity of CHVs in supported community units to identify and refer pregnant women for services, the project supported trainings on Community Maternal and Newborn Health (cMNH) technical module alongside Digisomo training in Napeililim, Kaitese, Lomil, Lokiriama, Koyasa and Meyan community units. The module focused on importance of ANC visits and danger signs during pregnancy. After the training, the CHVs were engaged in conducting mapping of pregnant women in their target households and subsequent follow up for ANC services. Additionally, 110 CHVs were provided with Digisomo gadgets to help them in relaying the thematic messages that are standardized and in local language.

To increase knowledge on sexual reproductive health and rights among the adolescents and youth, the project facilitated mentors to support youth discussion sessions on sexual

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reproductive health with the aim of promoting healthy behaviors among adolescents and youth and ultimately ensuring that pregnant teenagers attend ANC clinic. During the period under review, about three quarters (74%) of the women presenting with pregnancy accounted for adults (>19yrs), 25% adolescents (15-19yrs) and 1% adolescents (10-14yrs). In the subsequent quarter, the project through the SCHMT will map all the pregnant adolescents in every community unit and conduct data abstraction in every facility in order to identify the specific numbers of adolescents and youth seeking ANC services and link them to services with Binti Shujaa group.

Pregnancy Distribution Among Adults and Adolescents in Turkana County

25% % of adults (>19 yrs ) presenting with pregnancy % of adolescents (10 - 14 yrs) 1% presenting with pregnancy % of adolescents (15 - 19 yrs) 74% presenting with pregnancy

Figure 4: Pregnancy distribution among adults and adolescents in Turkana Sub-counties

Samburu County:

During the period under review, as shown in Figure 1 above, AFYA TIMIZA project enabled 2,732 pregnant women in Samburu East and Samburu Central sub counties of Samburu to receive ANC services for the first time in their recent pregnancy. Overall, a total of 1,206 pregnant women completed the recommended 4th ANC visit. This represents 44% (1,206/2,732) of the women who attended at least one ANC visit and 86% (1,206/1,410) of the quarterly target.

At the sub county level, the proportion of pregnant women who attended ANC at least four times has been on an upward trend for the last one year except for the month of February where services were affected by the Nurses strike. As shown in Figure 5 below, the highest increase was in Samburu Central Sub County.

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Proportion of Pregnant Women Attending 4th ANC According to Focused ANC Schedule in Samburu County

Figure 5: Proportion of pregnant women attending 4 antenatal care visits according to focused antenatal schedule in Samburu County (Source: KHIS)

To reach the unreached and underserved communities in Samburu County and ensure at least every expectant mother receives antenatal care services, the project supported integrated facility based outreaches, hard to reach outreaches, in-reaches and Umati in various sites in the county as shown in Table 3 below. A total of 227 women were served through facility based outreaches. The 227 were also provided with Basic ANC profile tests. 45 (20%) out of the 227 mothers were coming for their 4th ANC visit. At the hard to reach outreaches using the motor-mobile approach 109 mothers received ANC services with 48 (44%) coming for their 4th visit. The project also supported in-reach at the health facilities reaching a total of 49 mothers with ANC services with 7 (14%) attending their 4th visit. Through the health promotion desk, messages on importance of ANC visit were also shared. High risk clients were identified and counselled on how to manage pre-existing conditions and develop individual birth plan. Table 3: Distribution of ANC clients served by approach in Samburu County

# of ANC Proportio # of # of Clients n of ANC ANC ANC served Clients Clients Clients at served at ANC served served Facility Hard to at at In- based reach Health reache out- outreache Facility s reache s s New ANC clients 2585 93 18 36 ANC revisits 3594 134 31 73 At least 4 ANC Visits 1106 45 7 48

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To enhance capacity of health care workers, the project also supported distribution of policy guidelines, job aids and Mother Child booklets to the facilities during facility in-charges meetings. Some of the job aids taken to the facilities were on danger signs during pregnancy and basic ANC profile and their importance. Continuous Medical Education (CME) and On Job Training (OJT) sessions were also conducted where 32 HCWs (21 F and 11 M) were reached in Wamba health centre and Archer’s Post Health Centre. During the sessions, the topics covered were on goal for ANC visit , importance of ANC profile , commodities and equipment preparedness 4th ANC visit, SBA and right documentation using the correct reporting tools. To address malaria in pregnancy, the project will in the subsequent quarter continue to advocate for procurement of malaria related commodities like the malaria rapid test kits and mosquito nets by the county government and other stakeholders. To improve access to ANC services amongst youth and adolescents, the project through back pack (door to door) strategy engaged CHVs who sensitized pregnant young girls at the manyattas and during Lororas to ensure they receive ANC services. Adolescents and youth were mobilized to access services in health facilities as well as in the hard to reach and facility based outreaches. At the community level, the CHVs continued to sensitize mothers on the need to attend ANC clinics by demystifying the fears associated with ANC attendance and especially early ANC attendance. At the mother to mother support groups, members were highly encouraged to map out adolescent and teenage mothers and enroll them in the MTMSG so that they can benefit from the experience of the other mothers. As a result of these interventions, the project reached 67 (2%) (10-14yrs), 889(33%) (15-19yrs), and 65% adult expectant mothers. In the subsequent quarter, the project will support sensitization of HCWs on Adolescent and Youth package of care and this will improve the quality of care that is given to adolescent and youth pregnant mothers.

Pregnancy Distribution Among Adults and Adolescents in Samburu County

% of adults (>19 yrs ) 33% presenting with pregnancy % of adolescents (10 - 14 yrs) presenting with pregnancy 65% % of adolescents (15 - 19 yrs) presenting with pregnancy 2%

Figure 6: Pregnancy distribution among adults and adolescents in Samburu Sub-counties

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A. 2 LABOR AND DELIVERY

Obstetric care from a health professional during delivery is recognized as critical in reducing maternal and neonatal mortality. The expectation is that if complications arise during delivery, a skilled birth attendant can manage them or refer the mother to the next level of care. During the period under review, a total of 2,644 deliveries were conducted by skilled birth attendants in the project supported health facilities. The achievement represents 55% of 4,861 expected deliveries and 109% of the 2,433 quarterly target. Figure 7 below illustrates the number of expected deliveries, skilled birth attendants in health facilities and target for skilled attendance across the AFYA TIMIZA supported sub-counties in Turkana and Samburu sub counties.

In order to prevent, detect and manage complications during pregnancy and child birth, the project supported the sub-counties to build the capacity of HCWs to offer skilled delivery assistance, enhanced redistribution and positioning of life saving equipment, commodities and supplies, and promoted monitoring of interventions to ensure quality of services during child birth. To increase coverage, the project will continue to mentor and engage the CHVs on demand creation for ANC attendance and skilled delivery.

Deliveries by a Skilled Birth Attendant 6000 5000 4000 3000 2000 Number 1000 0 Turkana Samburu Samburu Loima Kibish Turkana Samburu Total South Central East Expected Deliveries 1151 1016 573 2740 1331 790 2121 4861 Number of Skilled Deliveries 683 493 337 1513 797 334 1131 2644 Target for Skilled Deliveries 565 476 193 1234 814 385 1199 2433 Live Birth 673 488 344 1505 761 328 1089 2594 % SBA against target 121% 104% 175% 123% 98% 87% 94% 109% Figure 7: Number of deliveries by a skilled birth attendant

Most (95.4%) of deliveries in the quarter were normal deliveries. Deliveries through Caesarean section and breech were 3.6% and 0.9% respectively as illustrated in Figure 8 below.

Distribution of Births by Type of Delivery

0.5% 100.0% 0.4% 1.6% 0.9% 3.6% Assisted vaginal delivery 95.0% 8.0% Breach Delivery 99.1% 95.4% Caesarian Sections

Percent 90.0% 90.5% Normal deliveries 85.0% Turkana Samburu Total

Figure 8: Distribution of births by type of delivery

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The specific activities that contributed to the performance are elaborated below by counties.

Turkana County

During the period under review, a total of 1,513 deliveries were conducted by a skilled birth attendant in health facilities. The achievement represents 55% of 2,740 expected deliveries and 123% of the 1,234 target for the quarter which is a slight drop from 128% achieved in the previous quarter. Figure 7 above illustrates the number of expected deliveries, skilled birth attendants in health facilities and target for skilled attendance across the AFYA TIMIZA supported sub-counties in Turkana County.

At the sub county level, a remarkable change has been observed in the delivery by skilled birth attendant coverage in the last one year. As shown in Figure 9 below, the highest increase in coverage was in Kibish and Turkana South Sub counties.

Delivery by Skilled Birth Attendance

Figure 9: Delivery by skilled birth attendant coverage in Turkana County (Source: KHIS)

In order to prevent, detect and manage complications during pregnancy and child birth, the project supported BEmONC assessment and distribution of BEmONC equipment to ensure the health facilities are prepared to handle obstetric and neonatal emergencies. To ensure proper use of these equipment, OJT especially on how to use the Vacuum extractors and MVA kits was done to the health care workers. In the subsequent quarter, the project through the SCHMT and County department of health will continue to support BEmONC assessment and redistribution of BEmONC equipment in the other facilities. To ensure availability of reference materials for the HCWs, the project also supported distribution of Warm chain charts, Assessment of the new born, Active management of 3rd stage of labor, labor flow chart management and assisted vaginal delivery charts. In order to build the capacity of CHVs in provision of maternal and new-born health services at the community level, the project through the SCHMT and AFYA TIMIZA technical officers supported training of 22CHVs (13M: 9F) on community based maternal and child health in Koyasa and Meyan community units in Kibish Sub County alongside Digisomo training. The Digisomo training was meant to build the capacity of CHVs in disseminating key messages on

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labor and delivery. Mentorship of CHVs in maternal and neonatal health was also conducted across all the community units supported in the three sub counties. The CHVs were sensitized during their monthly meetings on identification of pregnant mothers and strengthening prompt referrals for skilled deliveries. To ensure women from far flung areas access SBA in respectful manner, the project supported renovation of maternity shelters at Kaikor Sub County Hospital in Kibish Sub County. Napak, Loruth, Koyasa and Kanaodon dispensaries have also adopted maternity waiting shelter where community health volunteers and traditional birth companions have contributed locally available materials erecting the locally and culturally acceptable maternity shelters. To increase coverage of skilled delivery, the project will in the subsequent quarter continue to mentor and engage the CHVs, TBCs, religious leaders, Adakar leaders and Emurons on demand creation for ANC attendance and skilled delivery.

Samburu County

During the period under review, a total of 1,131 deliveries were conducted by skilled birth attendants in health facilities. The achievement represents 53% of 2,121 expected deliveries and 94% of the 1,199 target for the quarter. Figure 7 above illustrates the number of expected deliveries, skilled birth attendants in health facilities and target for skilled attendance across the AFYA TIMIZA supported sub-counties in Samburu County. There was a slight increase in skilled birth attendance (SBA) compared to the previous quarter and this also affected coverage. As shown in Figure 12 below, both sub counties reported a slight increase in the coverage for SBA.

Delivery by Skilled Birth Attendant Coverage

Figure 10: Delivery by skilled birth attendant coverage in Samburu County (Source: KHIS)

During the reporting quarter, the project continued to support routine services in the facilities to ensure clients receive SBA services that are of high quality and respectful to each mother. To strengthen Infection Prevention and Control (IPC) in the maternity units, the project distributed job aids to facility in-charges during data review meetings. The project also

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disseminated IPC protocols and guidelines to in-charges and distributed 80 aprons to health care workers in the sub county. To promote respectful maternity care, the project continued to mentor HCWs and CHVs on appropriate utilization of birthing cushion as an alternative for delivering in a squatting position which is considered culturally acceptable and comfortable by many women. For example, at the county referral hospital, use of the birthing cushion was preferred by 13 women in the reporting quarter. In addition, Lerata community health volunteers established a maternal shelter where women would come a few days earlier to wait for delivery in the facility . During the quarter, a few facilities received equipment such as portable ultrasound machines and baby warmers from USAID through KEMSA. The project staff visited these facilities to confirm delivery and installation. These equipment will help the HCW make timely and correct decisions on how to manage mothers and babies. In the coming quarter, the project will work closely with the county department of health and other stakeholders to do an equipment audit at the facilities to determine the need for rational redistribution in the facilities. The project will also support the county government to develop equipment management and maintenance plan to ensure there is routine maintenance. To strengthen coordination of MNCH services in the sub-county, the project supported sub – county TWG meeting in Samburu East where strategies on how to improve MNCH indicators like 4th ANC visit and SBA were discussed. In Samburu Central, the project supported redistribution of oxytocin and partographs by working closely with the county government. The project through a network of facility in-charges identified facilities with low stocks of uterotonics and supported in redistribution.

Figure 11: OJT on utilization of new baby warmer Figure 12: OJT on documentation at Archers Post machine at Ndonyo Wasin Dispensary HC

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During the period under review, facility in-charges in the peripheral facilities were encouraged to reach to the project technical officers for any kind of support or OJT. This was done in most cases through calls and WhatsApp and led to timely and appropriate intervention between BeMONC and CeMONC health facilities. Below is a case of Suguta dispensary for a woman who was timely referred to the county referral hospital.

Figure 13: Technical assistance through WhatsApp Maternal Complications

During the quarter under review, Postpartum Hemorrhage (PPH) was the leading maternal complication contributing to 53% of maternal complications as shown in Figure 13 below. Antepartum hemorrhage, ruptured uterus and sepsis were the second, third and fourth respectively.

Distribution of Maternal Complications

3% 0% 2% 100% 19% 19% 19% 0% 4% 2% 80% 6% 4% 5%

60% 52% 56% 53% 40% 20% 19% 19% 19% 0% Turkana Samburu Total

APH (Ante partum Haemorrage) PPH (Post Partum Haemorrage) Eclampsia Ruptured Uterus Obstructed Labour Sepsis

Figure 14: Distribution of maternal complications

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Turkana County

As illustrated in Figure 14 above, the leading course of maternal complication in Turkana County in the reporting period was Post-Partum Haemorrhage (PPH) at 52%, followed by Ante Partum Haemorrhage (APH) and obstructed labour recording the same number of cases thus each contributing to 19%, eclampsia was the third leading cause while sepsis followed with 3% of the complications. During the quarter, the project supported Quality Improvement (QI) mentorship sessions that included handling of obstetric emergencies in the health facilities. In addition, 10 HCWs (1F; 9M) were provided with CMEs on how to manage eclampsia, perform breech delivery and manage PPH in Kaikor Sub County Hospital. More emphasis was on ensuring availability of supplies and strategically positioning them for easy access when conducting emergency procedures. In the same period, one maternal death was reported at Kopeeto Dispensary, a case of Disseminated Intravascular Coagulopathy (DIC). Through the established facility MPDSR Committee, this death was audited and data uploaded into the DHIS2. To ensure the three delays are addressed, the project supported sensitization of the new MPDSR tools to the already existing MPDSR committees at the facility level in the three sub counties and further establishment of additional ten MPDSR committees in Loima. Through the SCHMT, the trained HCWs on MPDSR have been assigned the role of being MPDSR champions in their respective facilities as well as being mentors to the rest of the HCWs who have not been trained on MPDSR. They will ensure quality in reporting and auditing of maternal and neonatal deaths in their respective sub counties. To promptly identify and refer obstetric emergencies at the community level, the CHVs, TBCs and support staffs at the facility level were sensitized on their role in identification, referral and management of obstetric emergencies both at the household level and at the work place. Emphasis was put on recognition of APH, cord prolapse and eclampsia, prompt referral of clients seeking post abortion services. The CHVs and TBCs were also sensitized on post abortion care during the monthly data review meetings and quarterly community dialogue days. The project technical staff continued to build capacity of HCWs in management of maternal complications in pregnancy and delivery through continuous medical education and sensitization on utilization of UBT for management of PPH.

Samburu County

As shown in Figure 14 above, among women with pregnancy and labor related complications in Samburu, 56% were because of PPH, APH (19%), obstructed labor (19%), and eclampsia (4%). The project participated in the FP/RMNCAH TWG where key MNH indicators were discussed. Documentation of complications of pregnancy was noted as a gap in the facilities. The technical officers conducted OJT in 3 high volume facilities on how to correctly identify, record and report complications of labor and delivery. The project also worked closely with the health promotion officer and developed a schedule for health talks which included topics such as PPH, APH, eclampsia and/or including rhesus incompatibility. This is aimed at increasing the community’s knowledge on the complications and what to do in the event they occur.

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AFYA TIMIZA worked closely with the health department to build the capacity of ambulance drivers on basic life support and how to be team players in helping nurses when referring clients. The project also supported the MPDSR committee at the SCRH develop a referral protocol that was shared with all facilities in the county. The simple protocol provides a generalized to do list in order to promote continuity of care for the mother and the baby from BeMONC to CeMONC health facilities. In the next quarter, the project will continue to lobby for development and implementation of a referral strategy in order to improve referral systems in the county while also training the ambulance drivers on basic life support and handling of obstetric emergencies. Two of maternal deaths were reported and audited. They were due to Ante Partum Hemorrhage and eclampsia. Facility in-charges were provided with feedback on what could have been done to prevent preventable deaths.

Neonatal Outcomes

Table 4 below summarizes neonatal outcomes for Samburu and Turkana sub Counties

Table 4: Number and percent of neonatal outcomes Turkana Samburu Total No. Percent No. Percent No. Percent Still Births 16 1% 29 2.6% 45 1.7% Underweight babies <2500gms 27 2% 90 8.3% 117 4.5% Pre-term babies 27 2% 40 3.7% 67 2.6% Neonatal deaths 6 0% 14 1.3% 20 0.8%

Turkana County In the reporting period, still births accounted for 1%, underweight 2%, preterm 2% and neonatal deaths 0.4% of neonatal outcomes as shown in Table 4 above.

The project through the MPDSR committees continued to track facilities MPDSR implementation and audit findings and recommendations for improvement of maternal and neonatal health outcomes based on the report findings. Through the SCHMT, Sub-county based biannual MPDSR forum will also be held for sharing best practices and lessons learnt.

Samburu County

During the quarter, maternal and 43 perinatal deaths were reported and audited at the facilities. The perinatal deaths audit indicated that they were due to asphyxia. The project will continue strengthening the MPDSR committees at the facility level for timely surveillance, reporting and execution of action plans to prevent further mortality.

The project also supported strengthening of the sub-county management teams by ensuring that they include MPDSR as one of their agenda in their monthly meeting. The project also supported printing of notification and audit forms for the committees. Through the MPDSR committees, action points were developed and most of the immediate action points have been implemented. The table shows a summary of action points implemented versus those ones pending:

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Implemented Action Points Pending Action Points OJT to nurses on documentation and history taking Development of a referral policy Communicate to referring facilities on action Points Employ NBU dedicated nurse Development of referral protocols Employment of a neonatologist/paediatrician Initiation of KMC at SCRH Development of various hospital specific EmONC protocols CME for HCWs on: Availability of Oxygen in labor and NBU wards i. KMC ii. Documentation iii. History taking iv. Newborn Resuscitation v. Obstetric emergencies vi. Misoprostol protocols Improvement of IPC practices: Construct/setup a satellite blood bank. i. Minor renovations of the NBU ii. Procurement of green towels iii. Provision of colour coded bins Ultra sound for all the ANC mothers at 1st and 3rd trimester Sensitization of the CHVs on mapping of ANC mothers, early detection of danger signs, referral and follow up

At the county referral hospital, the project supported roll out and strengthening of Kangaroo Mother Care (KMC) by providing wrappers/pouches and gowns. This will strengthen management of all underweight and premature new born babies. So far, 20 babies have benefited from intermittent KMC services at the facility. The baby warmers supplied to most maternity units will also help to improve new-born outcomes. Follow up of babies who are discharged from KMC was also initiated and will be integrated into routine MCH services at the referral hospital

Figure 16: KMC at Maternity Unit Figure 15: Follow up of a baby discharged from KMC at in SCRH the MCH department

Post Abortion Care (PAC)

Turkana County Post abortion care is lifesaving care, and is one of the signal functions for emergency obstetric care that should be offered in a health facility. As depicted in Table 5, a total of 20 clients accessed the service with 4 adolescents and 16 adults (>19years) receiving the services.

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Table 5: Post Abortion care services Turkana County Turkana Kibish Sub Loima Sub Indicator South Sub County County County Adolescent (10-19yrs) accessing PAC 1 0 3 services Women accessing PAC services 5 3 8 Total 6 3 11

The reported abortions were spontaneous from women with planned pregnancies, and not cases of induced habitual, clandestine and or abortions from rape/GBV survivors. The clients received the recommended package for PAC, including counseling for family planning and were subsequently followed-up until full recovery. No cases of maternal mortality resulting from abortion were reported. The increase in the number of cases is attributed to a number of activities supported by the project, most of which were addressing the stigma associated with abortion and resultant inability to seek for the health care services. The project continued to sensitize the community through the various groups like CHVs, TBCs, mother to mother support groups and religious leaders in the community on the factors predisposing to abortion and the importance of seeking early PAC services. The project also sensitized the community on the importance of FP in alleviating the cases of abortion especially among the adolescent and youth. The groups in the community are engaged regularly and especially on a monthly basis for mentorship, lessons learnt and sharing of challenges. Infection prevention and control practices and safe storage of MVA kits was ensured in facilities that have the capacity to offer the services. Issues of privacy and confidentiality for clients remains one of the key quality components during and after the service provision that was adhered to. The project will continue lobbying for more MVA kits to be procured by the county through the facility improvement fund. Additionally, facility staff continued to receive sensitization on the policy of protecting life in global health assistance. The project also continued to support active dissemination of health information on abortion and post abortion care in the community through different forums by the existing community health groups.

Samburu County As shown in Table 5, a total of 6 clients accessed the service among them, 2 adolescents and 4 adults (>19years). In order to strengthen PAC services, facility in-charges were sensitized on the need to have equipment and supplies needed to manage all clients coming for PAC services. The RH coordinators were tasked to ensure that all supplies are included in the list of EMMS and to help facilities procure equipment such as MVA kits. Facilities were advised to label the MVA kits in the facilities so that they are only used for PAC services. The project supported in strengthening comprehensive PAC services through OJT, CME and mentorship on correct clinical management and referral. Clients were also counselled and offered FP services.

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To strengthen timely referral for all mothers who require PAC services, CHVs and birth companions were sensitized on how to identify post-delivery dangers signs and in women who might have miscarried or procured abortion at home. The birth companions were encouraged to reach out to the TBAs that might still be operating in the villages and enlighten them on the dos and don’ts in such cases.

Table 6: Post Abortion care services Samburu County Indicator Samburu Central Samburu East Adolescent (10-19yrs) accessing PAC 1 1 services Women accessing PAC services 1 3 Total 2 4

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A.3 POSTNATAL CARE

Table 7: Number mothers provided with post-natal care services in Turkana County Turkana Period Data Kibish Loima Totals South PNC women counselled 293 797 946 2036 PNC Mothers receiving PNC within 2-3 days 281 390 629 1300 PNC Mothers receiving PNC within 6 days 27 220 524 771 PNC Cervical Cancer screening 0 3 0 3 PNC Breast examination 238 784 896 1918 PNC Fistula cases 0 0 0 0

Apr to 2019 Jun PNC referrals from Community Unit 203 396 407 1006 PNC referrals to Community Unit 235 368 469 1072

Table 7 above shows the summary of post-natal service delivery in Turkana County across the three supported sub counties. During the quarter under review, a total of 2,036 women were counselled on post-natal care which has decreased compared to 2,103 who received post-natal counselling in the second quarter. For those counselled, 1,300 mothers received post-natal care within 2-3 days, 771 women received the care within 6 days and 3 received cervical cancer screening. A total of 1,918 had breast examination done. There were no PNC Fistula cases reported across the three sub counties. With the support of the religious leaders TOTs, TBCs and the CHVs in strengthening the uptake of post-natal care service in their link facilities, a total of 1,006 women were referrals from the community units for PNC services and finally 1,072 PNC referrals to the community units. From the review of Table 7 above, there was only a coverage increase for the women receiving post-natal care within 6 days and a decrease is noted in all other PNC indicators including PNC referrals from and to community units as compared to the previous quarter. The increase noted is attributed to combined efforts from the project staffs technical assistance, SCHMT members, facility staffs who were trained on PNC, proper documentation and the active role of referrals played by the trained CHVs in the supported sub counties. In the previous quarters, the project through Kenyatta University trained most of the facility staff on cervical cancer screening and PNC courses and during the quarter some sub counties for example Kibish sub county trained staff had no supplies like lugols iodine and acetic acid to continue with the screening even though the project supported the facilities with the screening reporting tools and cervical cancer registers.

Generally, a review of the sub county PNC coverage shows remarkable change in PNC attendance in the last one year. As shown in Figure 17 below, the highest increase in coverage was in Kibish and Turkana South Sub counties.

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Post Natal Care Attendance Coverage in Turkana County

Figure 17: Postnatal care attendance coverage in Turkana County (Source: KHIS)

In order to strengthen the uptake and improve the PNC coverage in the next quarter, the project will lobby with the SCHMT members on the provision of screening commodities and supplies for the facilities in order to continue with the provision of cervical cancer screening services. Also due to inadequacy of cervical cancer screening commodities, the SCHMTs advise the facility in charges to budget and purchase these commodities and supplies through the Health Sector Service Fund (HSSF) allocated by the government to most of the directly supported facilities. More efforts will be put during the CHVs monthly meetings and facility data review meetings to strengthen community PNC referrals and proper documentation & provision of PNC services respectively. This will further be strengthened by ensuring that quality PNC services are given and documented through OJTs and mentorships. The project technical officers will support the SCHMTs to put more efforts in guiding HCWs in all facilities to ensure that all the women delivering in the health facility are given the initial PNC services and are recorded in the register before they are discharged. This will be strengthened further by strategically positioning PNC registers at maternity and immunization SDPs to reduce missed opportunities in service provision and documentation. The fact that most of the community units have now been trained on the talking books (Digisomo) and some CHVs issued with these gadgets, the project demand creation teams will follow up on this closely to ensure they are actively utilized in order to provide adequate key messages to the community on PNC services at household level and referral of clients as recommended. The project will also utilize the FPRMNCAH piloted register in the community units for the CHVs which aims at tracking women from conception, delivery, postnatal, family planning, child immunization up-to post child immunization period to improve PNC coverage and PNC referrals from and to community units.

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Samburu County Table 8 below summarizes post-natal service delivery across the two sub-counties. During the period under review, a total of 1,250 women were counselled for postnatal care services where 583 mothers received the service within 2-3 days while 238 received it within 6 days.

Table 8: Number mothers provided with post-natal care services in Samburu County Samburu Period Data Samburu East Totals Central PNC women counselled 592 658 1250 PNC Mothers receiving PNC within 2-3 days 252 331 583 PNC Mothers receiving PNC within 6 days 97 141 238 PNC Cervical Cancer screening 7 0 7 PNC Breast examination 540 683 1223 PNC Fistula cases 3 10 13

Apr to 2019 Jun PNC referrals from Community Unit 24 122 146 PNC referrals to Community Unit 41 82 123

The project continued to support health facilities to provide quality postnatal care services. To reduce missed opportunities for PNC, AFYA TIMIZA supported service integration of PNC into other departments like maternity, immunization and nutrition clinic. In the later, the nutritionists will ask for the mother child booklet for all children under 2 years to check for immunization status as well as PNC follow up. Lack of Chlorhexidine (CHX) use for cord care and Vitamin K in the facilities was identified as gap in the county. The FP/RMNCAH TWG recommended to the county pharmacist to ensure that these commodities are procured together with the other supplies. To strengthen and scale up PNC services, the project supported CME and OJT sessions for 11 HCWs (7 F: 5 M) and 14 CHVs (F: M) on integration of PNC during routine immunization days in all immunizing facilities. During the quarter, the project also built the capacity of HCWs to flag out all the mother bringing their children for immunization and receive provider initiated postnatal services. Targeted CMEs and OJT will continue to be supported to address identified capacity gaps and especially for the newly recruited health care workers. In addition, the project will continue using the CHV’s to educate mothers on use of CHX for cord care and also follow up for completion of PNC as well as babies who require KMC. To strengthen follow up of babies who are discharged in maternity, staff in MCH have been sensitized on KMC to ensure continuity of care and follow up.

While access to PNC has increased significantly in the County PNC delivery at the facility and community level still faces some system challenges that have equally led to fluctuations in the coverage as shown in Figure 18 below:

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Post Natal Care Attendance Coverage in Samburu County

Figure 18: Postnatal care attendance coverage in Samburu County (Source: KHIS)

A.4 CHILD HEALTH

Immunization:

In order to make sure children survive and thrive, the project supported child immunization program in the target Samburu and Turkana Sub-Counties. This section reports on EPI interventions supported by the project. Table 9 below summarizes number of children immunized against the APR target in Samburu and Turkana Counties.

Table 9: Number of children immunized OPV excluding birth Pentavalent 3 Pneumococcal 3 FIC polio

Target Target Target Target

Achieved Achieved Achieved Achieved

% Coverage % Coverage 1Yr

County Pop Targeted % Achievedagainst target % Achievedagainst target % Achievedagainst target % Achievedagainst target Estimated Number of Children < Estimated Number of Children < Turkana 4448 973 564 58 973 1001 103 23 4448 973 742 76 17 858 909 106 South Loima 3925 821 1301 158 821 909 111 23 3925 821 740 90 19 725 748 103

Kibish 2213 333 331 99 333 393 118 18 2213 333 321 96 15 294 425 145

Turkana 10,586 2,127 2,196 103% 2,127 2,303 108% 22% 10,586 2,127 1,803 85% 17% 1,877 2,082 111 Samburu 4878 1,127 1299 115 1,127 1307 116 27 4878 1,127 623 55 13 994 1,039 105 Central Samburu 2894 573 779 136 573 758 132 26 2894 573 586 102 20 506 603 119 East Samburu 7,772 1,700 2,078 251 1,700 2,065 248 27 7,772 1,700 1,209 71 16 1,500 1,642 109 Grand 18,358 3,827 4,274 112% 3,827 4,368 114% 24% 18,358 3,827 3,012 79% 16% 3,377 3,724 110% Total

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Table 9 above indicates that 110% (3,724/3,377) of children were fully immunized during the quarter. Achievement for children given 3 doses of pentavalent and 3 doses pneumococcal were 114%, and 79% respectively. The county specific interventions are as described below.

Turkana County Turkana County achieved 111% FIC during the reporting quarter. Fully immunized children performance in Kibish, Loima and Turkana south were 145%, 101% and 106% respectively. The quarterly county performance of OPV3, Pentavalent3, and Pneumococcal3 were 103%, 108%, and 85% respectively. Kibish sub-county leads in both full child immunization and third doses antigens.

Generally, the trend for the proportion of children under one year who are fully immunized had been on a decline but remarkable improvement has been reported in the last 3 months. As shown in Figure 19 below, the improvement was noted in all the three Sub counties.

Proportion of Children Under One Year Fully Immunized in Turkana County

Figure 19: Proportion of children under one year who are fully immunized in Turkana County (Source: KHIS)

During the reporting period, the project supported various approaches which include integrated health outreaches, on job training, technical assistance to facility and community units, and antigens supply chain logistical support. In Kibish sub-county 22 CHVs in Koyasa and Meyan community units were trained on MNH modules and they were tasked to map all the under one children in every household and follow them through till completion of immunization. The defaulter tracing mechanism for immunization was also strengthened through CHVs and TBCs across all the community units supported with enhanced referral and linkages for services at link facilities and during outreaches. The facilities were also supported to line list immunization defaulters who missed appointments after the clinic day and shared to CHVs for prompt tracing.

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The SCHMT and AFYA TIMIZA staff provided technical assistance to health care workers on children immunizations scheduling and daily immunization policy at all facilities in the three sub-counties. On job training was conducted in Kibish sub-county facilities on vaccine forecasting for utilization both at the facilities and outreach sites. This will enable consistence in antigen supplies and address overstocking and understocking. The HCWs were also taken through routine checks and vaccine fridges functionality at Lokamarinyang dispensary which had a minor fault in the thermostat. In Turkana South and Loima sub counties, facilities with low immunization performance were identified and listed with help of MNCH score card and sub-county facilities dashboards. This facilities are; Kagitankori, Lorogon, Lokichar RCEA, Lokaburu, Loyapat, Korinyang, Kapelbok, Urum, Nasiger, Lochorekuyen, Turkwel, Lorugum, and Nameyana. This facilities will be followed up in quarter four for close monitoring and technical support to improve immunization performance.

The project scaled up support of integrated health outreaches from 7 sites to 20 sites in Turkana south in efforts to reach marginalized children and women unable to reach facilities because of drought. This enabled a total of 512 children be reached with immunizations in remote villages. During the quarter under review, the sub-counties experienced OPV antigen stock out. Antigens, and diluents redistribution across the facilities was conducted to curb the acute shortages at some facilities. During antigens redistribution, EPI reporting tools i.e. vaccines ledger booklets, Temperature charting booklets and mother baby booklets were also supplied to all facilities at the beginning of the quarter.

Table 10: Number of children reached at various service delivery points in Turkana County Proportion of Under 5 Proportion of Under 5 reached with reached with services at services at Facility based out-reaches Health Facility DPT3 2,111 (92%) 192 (8%) PCV3 1,671 (93%) 132 (7%) Measles 1,877 (91%) 188 (9%) Treated for 5,948 (98%) 123 (2%) Diarrhea

Samburu County

As shown in Table 9 above, AFYA TIMIZA project managed to reach 109% children under one year in Samburu County with all the primary antigens required for a child to be fully immunized (FIC).

Generally, the trend for the proportion of children under one year who are fully immunized had been on a decline but remarkable improvement has been reported in the last 6 months, as shown in Figure 20 below:

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Proportion of Children Under One Year Fully Immunized in Samburu

Figure 20: Proportion of children under one year who are fully immunized in Samburu County (Source: KHIS)

To reach children in areas far from the facility and ensure they are protected against vaccine preventable illnesses, the project supported facility based outreaches in 25 sites in Samburu county and facility in-reaches in 3 facilities where 624 and 61 children were reached with immunization services respectively. The health care workers in the outreach passed messages to the mothers on importance of vaccines and hospital delivery. The project also supported hard to reach outreaches reaching 124 children with immunization services. During the quarter, the Division of vaccines and immunization (DVI) introduced a new multi- dose vial for PCV 10. Before the vials were available in the county, there was a stock in many facilities causing the disparities between number receiving PCV-3 and DPT-3. When the new multi-dose vial was available, the project provided technical assistance during the sensitization sessions as well as ensuring the same knowledge reached all staff in facilities where there are more than 1 staff. To prevent stock out of antigens in the far to reach facilities, the project also supported redistribution of vaccines from the main KEPI store to the 15 rural facilities in Samburu East as well as mentorship on vaccine quantification and forecasting. After lobbying for an increase in immunizing facilities in the previous quarters, the county government procured and installed 2 fridges increasing the immunizing facilities from 20 to 22 in Samburu East. During the quarter under review, the project supported county maintenance personnel to repair 4 faulty fridges in Samburu Central. This was aimed at enhancing access and utilization of immunization programme and was integrated in the support supervision to facilities. To reduce number of immunization drop out, the project engaged CHVs and conservancy scouts to conduct defaulter tracing and health education on importance of immunization at the household level. The project also supported the HRIOs to conduct immunization data verification at the facility level. Some facilities were noted to have reported having given yellow fever vaccines and have

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had adverse effects following immunization. The HRIOs were tasked to work closely with the facility in-charges and ensure that data that goes into DHIS2 is cleaned. Facilities were also encouraged to do data reviews before submitting data to the sub-county team. To build the capacity of HCWs to strengthen delivery of immunization services, the project supported several capacity building approaches such as mentorship and OJT to reach the health workers in the facilities. The table below shows the topics covered with numbers reached:

Mentorship/ OJT No of Staffs reached Filling of the ledger books 15 HCWs ( 11F:4 M) Immunization monitoring chart 8 ( 5 F: 3M) Integrations of outreach and facility immunization data 17 ( 10 F: 7 M) Vaccines forecasting and vaccines ordering 6 ( 4 F: 2 M ) Filling of MOH 710B 11 ( 7 F: 4 M) Morning and evening temperature chart 6 ( 3F: 3M)

AFYA TIMIZA continued to support strengthening of defaulter tracing mechanisms through updating the hard cover book by using the immunization register and referring the children who did not turn up for the immunization to be traced back by the CHV. During the quarter 129 children who had defaulted were traced and referred for immunization services. In the sub sequent quarter, the project will work with the county government to launch the HPV vaccine for all the girls under the age of 10 years in the county.

Integrated Management of Childhood illnesses

Turkana County

Table 11: Top ten causes of morbidity for under five children in Turkana Apr - Jun 2019 Turkana Period Data South Loima Kibish TOTAL Upper Respiratory Tract Infections <5 yrs 9269 7,805 2,623 19697 Diarrhoea <5 yrs 2754 2066 1251 6071

Confirmed Malaria (only Positive cases) <5 yrs 2736 1,163 242 4141 All other diseases <5 yrs 1553 946 310 2809 Other Dis. Of Respiratory System <5 yrs 1169 714 275 2158 Pneumonia <5 yrs 790 706 165 1661 Suspected Malaria <5 yrs 730 602 90 1422 Disease of the skin <5 yrs 710 344 222 1276 Apr to 2019 Jun Fevers <5 yrs 223 667 145 1035 Eye Infections <5 yrs 434 225 372 1031

Childhood morbidity is a public health threat to wellbeing of children, growth and development. Turkana County caseloads of top four morbidities have significantly reduced in the last 2 quarters. Upper Respiratory Tract Infections cases increased from 13,503 in Q2 to 19,697 in Q3, diarrhea also increased from 5,331 to 6,071, malaria from 2,951 to 4,141 and pneumonia from 990 to 1,661. Upper respiratory infections, diarrhea and malaria are the leading causes of childhood morbidity across all the sub-counties with almost 50% increase in caseloads compared to quarter two. Kibish sub-county has low caseloads compared to other sub-counties. In the quarter under review, the project continued to build capacity of health care workers on proper case definition and proper treatment for childhood illnesses as per IMCI guidelines. At the community level, the CHVs were sensitized during their monthly review meetings on how to accurately identify cases at the community level and treat using zinc and ORS and referral of complicated cases as ICCM.

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In Kibish sub-county, the ICCM ToTs conducted assessment on trained CHVs to ascertain their knowldge and maturity in management of childhood illnesses at the community level. CHVs were also involved in case finding at the community and carrying out prompt referrals for cases that could not be managed at the community level. In the quarter under review, the project continued to mentor health care workers on integrated management of childhood illness in all the directly supported health facilities. Through the various innovative approaches, 873 cases amongst children under 5 years were managed for various ailments in top ten conditions during the month; 11 cases of fever in children under 5 years were managed. Diarrhoea: Diarrhoeal illness is the second top morbidity across all the sub-counties. It has high mortality rate if not promptly managed at household and facility level with simple available remedies. The project continued to strengthen the capacity of health facility and community units in management of diarrhoea. During the quarter under review, the project continued to strengthen the management of diarrhoea through oral rehydration therapy (ORT) corners establishment at the facility level. During the outreaches, the CHVs supported distribution of purr for water treatment at the community level. CHVs also gave health education on importance of hygiene maintainance at the household level and protection of shallow water points to prevent emergence of diarrhoeal outbreaks. In quarter three, the project will continue supporting trained CHVs to disseminate hygiene messages through Digisomo talking books at the community level as well as facilitating SCHMT to mentor healthcare workers on integrated management of childhood illnessnes.

Samburu County Table 12: Top ten causes of morbidity for under five children in Samburu Apr - Jun 2019 Top 10 <5 morbidity Samburu County Samburu Period Data Central Samburu East TOTAL Upper Respiratory Tract Infections <5 yrs 8122 4011 12133

Diarrhoea <5 yrs 1939 1335 3274 Other Dis. Of Respiratory System <5 yrs 1514 737 2251 Pneumonia <5 yrs 2238 321 2559 Disease of the skin <5 yrs 809 500 1309 Confirmed Malaria (only Positive cases) <5 yrs 856 159 1015 Eye Infections <5 yrs 380 373 753 Fevers <5 yrs 255 156 411 Oct to Dec 2019 Dec to Oct Tonsilitis <5 yrs 923 133 1056 Ear Infections/ Conditions <5 yrs 360 236 596

Diarrhea To increase the uptake of services in the hard to reach areas, AFYA TIMIZA conducted integrated outreaches. This was an opportunity to attend to children who suffered from diseases. In Shaplo, one of the outreach sites in Samburu East, a nine year old child was treated for chicken pox. During the same period 122 children were treated for pneumonia. At the community level, the project through its Technical Advisory Committee (TAC) recommended to the county to consider training CHVs on ICCM technical module so as to build the capacity of CHVs to handle childhood illnesses at home. This will also strengthen follow up of sick children at the community following discharge as well as helping avert child mortalities from diarrhoea and pneumonia.

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At the facility levels, the project worked closely with the sub county pharmacists to ensure that facilities had enough stocks of antibiotics for treatment of pneumonia and ORS+Zinc for management of diarrhoea. Facilities were encouraged to report bi-weekly on the stock status for this commodities. The project also collaborated with CHAI to conduct IMNCI assessments in the facility to assess and strengthen management of diarrhoea and pneumonia. The project also continued to strengthen ORT corners to enhance correct management of diarrhoea for under 5 children. This was done by ensuring the corners are equipped and stocked at all times. As personal hygiene is key in diarrhoea prevention, the project supported targeted heath education sessions for pregnant and lactating in 6 Umati sessions in the county. Hand washing during the four critical times was emphasized for the mothers and guardians present during the sessions.

B: FAMILY PLANNING (FP)

Table 13 below summarizes achievements for Uptake of family planning commodities among women of reproductive age.

During the quarter under review, the project reached 8,078 WRA with modern FP. Of these, 6,815 (84%) received short acting FP commodities while 1263 (16%) received long acting methods. The CYP for the quarter was 6,663 against the set quarterly target of 7311, an achievement of 91%. The project supported sites continued to ensure compliance to FP legislative policies and PLGHA. The project through CHVs, religious leaders, men and women groups will continue educating the target communities to demystify myths and misconceptions on family planning and encourage adoption of healthy practices of healthy timing and spacing of pregnancies. In addition, targeted capacity building including mentorship to build confidence in provision of LARC and commodity security for method mix will continue.

Table 13: Uptake of family planning commodities among women of reproductive age (Apr– June 2019) Turkana Samburu Samburu South Loima Kibish Turkana Central East Samburu Total Population of WRA 11450 10104 5695 27249 7178 4258 11436 38685 Number of WRA receiving FP 2268 599 264 3131 3451 1496 4947 8078 commodities Total clients receiving short- 2086 525 252 2863 2884 1068 3952 6815 acting FP commodities Total clients receiving long acting 182 74 12 268 567 428 995 1263 FP commodities Proportion receiving Long 8% 12% 5% 9% 16% 29% 20% 16% Acting Method WRA receiving FP commodities 20% 6% 5% 11% 48% 35% 43% 21% (coverage)

Turkana County

The coverage for uptake of FP services in Turkana County was 11% of the expected 27,249 WRA, a drop from 13% in the previous quarter. The three regions Turkana South, Loima and Kibish presented a coverage of 20%, 6% and 5% respectively. 91% of the 3,131 WRA reached opted for short-acting contraception while the rest 268 accepted long-acting and reversible methods.

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For the uptake of short-acting FP commodities, Turkana South in comparison with Kibish and Loima sub counties reached 72% (2288) of the clients with services. However, for the proportion of WRA receiving LARC commodities the coverage for the three sub counties was <10% a drop of 1% from the previous quarter. The coverage of Youth and Adolescents stood at 33% in the three sub counties.

Some of the drawbacks in the uptake of FP services were transfers of trained personnel to other health facilities in a County-wide reshuffle. It was also evident that some health facilities were not yet operational for lack of qualified staff like Lobulono in Kibish, Lomeleku, Nalemkais, and Kaakalel in Turkana South.

During this period, 75 CHVs were trained on FP from six (6) CUs (2 in Kibish Sub County and 4 in Loima Sub County). Adolescent and Youth meetings for high volume facilities in all the three sub counties were conducted to create awareness for FP information and services. 20 Integrated outreaches in Turkana South enhanced information and services sharing among WRA in rural communities.

In May 2019, Turkana South sub-county benefited from a 2-day Free Medical camp and cervical cancer screening supported by Ministry of Health, Turkana County Government, AMREF, KEMSA, AMPATH and other partners. Each of the three SCHMTs were supported to conduct supportive supervision to ensure quality assurance and improve learning and identification of service delivery gaps.

During the period under review, the project facilitated the CHVs to reach the community with FP messages using ‘DigiSomo talking books’ with thematic messages translated to the local language. In the subsequent quarter, a training for three Napak CHUs on DigiSomo talking books/radio is earmarked to support uptake of FP services through referral of clients. The project will also continue to conduct Adolescent and Youth forums in high volume facilities to bolster demand for APOC services in the sub counties. Other approaches to enhance acceptance of contraceptives include Adolescent and Youth sensitization sessions in safe spaces like the high volume health facilities and schools. Trained TOTs on reproductive health services in Kibish will work with the health workers, CHVs and TBCs helping package information on reproductive health for the youth and adolescents.

The project will continue engaging community resource persons like Emurons (Ngimurok) in kraals, religious leaders, FBO facilities to support in information sharing and referral clients for reproductive health services.

Table 14: Uptake of FP commodities in CCC clinics (Apr-Jun 2019) Turkana Service access unit Kibish Loima Total South Clients accessing FP services in 7 24 40 71 CCC Total 7 24 40 71

AFYA TIMIZA continued to enhance integrated services in HIV clinics and other service delivery points. During the period under review, a total of 71 clients attending the CCC clinics were counselled and provided FP services based on their medical eligibility criteria. The project will continue coaching and sensitization HCWs on method mix and quality of care in family planning. The project has also continued sensitizing CHVs to support in basic counselling and referral of clients for reproductive health services. Facility data review meetings, supportive supervision with the SCHMTs has been helpful in determination of health service delivery gaps.

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Samburu County

Inadequate information, myths and misconceptions in the community among men and women are the main barriers to uptake of modern contraceptives. In the period under review, the project continued to engage trained CHVs to provide information on family planning and refer clients for FP services. A total of 1031 clients were referred for FP services by the CHVs for various contraceptive methods in the facilities. The project also supported 8 monthly meeting for CHVs which provided a platform for sharing and learning on approaches of providing information on family planning at community level.

Women were also sensitized on birth spacing and healthy timing of pregnancy as well as cervical cancer screening through a church conference and congregational model in PCEA Church and Jamia Mosque in Maralal respectively, 60 people were reached with the information and 8 women screened for cervical cancer with 1 suspected case found. Additional 29 (M=11: F=19F) CHVs were trained on family planning technical modules with integration of Adolescents and youths (A&Y) accelerator behaviour, and Sexual and Gender Based Violence((S)GBV) Figure 21: Clients receiving services in a Facility Based Outreach at Amayia community messages. In the subsequent quarter, the project through the community health extension workers will mentor the trained community health workers to further increase their capacity to provide family planning services and referrals at community level.

To strengthen integration of cervical cancer screening in FP clinic at the county referral hospital, the department was supported with 1 Litre of Lugols Iodine by AFYA TIMIZA where 13 women were screened.

Inaccessibility of health facilities has led to unmet FP need among women in semi-arid areas. To increase number of women accessing family planning services, the project supported facility based integrated outreaches and in-reaches reaching 114 women.

The project also supported one in-reach in Samburu Central in which 12 women were screened for cervical cancer out of which 2 were suspicious for cancer and were referred for further evaluation.

Missed opportunities contribute to unmet need among women seeking other health services. To increase family planning service provision at every point of contact, AFYA TIMIZA continued to strengthen integration of family planning with other services. The project conducted a CME of 11 staff working in TB and HIV departments on integration of family planning with HIV and TB Figure 22: CME on integration of FP to HIV services services. The project will in the subsequent in Wamba Health Centre quarter support the departments to scale up provision of family planning services to minimize

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missed opportunities in CCC, immunization, maternity and female ward SDPs.

Through the use of PHE approach at the community level, engagement and involvement of men in family planning has greatly increased. The approach was employed through the CHVs who move door to door and sensitization during barazas to ensure men are well informed on the need to support their partners on family planning. During the quarter under review, in 15 barazas, men were sensitized on FP/RMNCAH using PHE approach in different sites in the hard to reach areas. As a result, more men accompanied their wives for family planning services and out of 1874 women who were sensitized on family planning 453 received service during the outreaches. To increase the uptake of family planning to the youth

Figure 23: Morans receiving counselling on and adolescent, Afya Timiza offered services at night in FP/RMNCAH from a HCW during the the camp outreaches where 11 morans brought their outreaches in one of the sites in the hard to reach areas. partners for services and 15 girls in school and out of school presented for family planning services.

Method Mix

Method Mix - AFYA TIMIZA 524, 7% 167, 2% 1166, 14% Pills Emergency Injectables 1434, 18% 3524, IUCD 0, 0% 44% Implants 1075, 13% Sterilization 188, 2%

Figure 24: Family planning method mix

Turkana County Method Mix in Turkana County has been skewed towards short-acting family planning commodities as evidenced by a 91% acceptance compared to a 9% for long-acting FP services. Other methods including natural family planning, cycle beads were accepted by 37% of the clients reached. 595 or 19% of the clients reached preferred condoms whereas 873, 28% accepted injectables. Barrier methods, Injectable and natural methods remained as the three favorable methods of choice in the three sub counties.

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Method Mix -Turkana

176, 6% 69, 2% Pills Emergency Injectables 1150, 37% 873, 28% IUCD Implants Sterilization Condoms 595, 19% 74, 2% Other Methods 194, 6% 0, 0%

Figure 25: Family planning method mix in Turkana County

Adolescents, Youth in School and Out of school were reached through SBCC channels. Cervical cancer screening and family planning uptake has also been integrated. The project also used coaching and mentorship of health workers on professional counseling skills and medical eligibility criteria for clients. AFYA TIMIZA worked with SCHMTs on commodity management gaps, orders and timely supply during supportive supervisions. The project officers intensified coaching and mentorship for HCWs on FP method mix as well as supporting use of data for quality improvement and decision making.

Trends of Method Mix in Turkana County (Jul 2018 to Jun 2019)

Apr to Jun 2019 6% 30% 3%1% 20% 39%

Jan to Mar 2019 5% 2% 24% 5% 1% 22% 40%

Oct to Dec 2018 5% 4% 32% 6% 1% 22% 31%

Jul to Sep 2018 6% 3% 31% 3%2% 21% 33%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pills Emergency Injectables IUCD Implants Sterilization Condoms Other Methods

Figure 26: Trends in family planning method mix in Turkana

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Samburu County To mitigate stock out of family planning commodities and enhance method mix, AFYA TIMIZA continued strengthening commodity management and reporting in the facilities. A WhatsApp group was introduced in Samburu Central Sub County through which facility in charges share updates on stocks and expiry dates for FP commodities fortnightly. This has helped the SCRHC, the county and sub county pharmacists to know which commodities have short expiry for redistribution to avoid expiries in facilities as well as equitably redistribute commodities across the facilities. Through the platform, HRIOs are also alerted on data discordance for verification and corrections in Figure 27: Sample of Commodity update DHIS2. In the next quarter, the project will using WhatsApp platform continue to actively engage health care providers on use of the platform to share knowledge and update colleagues on new updates. The project will also continue to strengthen community Family Planning (cFP) by continuously mentoring CHVs on counseling and referrals of clients on FP services and male engagement during household visits. Lack of information on broad range of family planning methods is a barrier to method mix in family planning uptake. This can come about especially when service providers give information only on certain methods during family planning counseling. To mitigate this gap, AFYA Timiza supported facilities to establish and use family planning demonstration trays as well as display charts during counseling which ensured the session provided a range of information on family planning. This teaching aids are essential in providing proper counseling to women Figure 28: Demonstration box in Ngilai dispensary particularly those who cannot read or write.

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Method Mix - Samburu 16, 0% 348, 7% 98, 2% Pills Emergency 839, 17% 0, 0% Injectables IUCD 881, 18% Implants 2651, 54% Sterilization Condoms 114, 2% Other Methods

Figure 29: Family planning method mix in Samburu

Family planning (FP) uptake among youth:

Turkana County

Among the adolescents and youth targeted with FP information and services, 70% were aged 20-24 years. 162, 17% were aged 15-19 years while 13% were aged 10-14 years old. Demand creation with targeted messaging for youth was supported and health workers were sensitized on being youth friendly. In the subsequent quarter, the SCHMT TOTs, project technical officers with the help of adolescent & youth technical officer and social and behavior change communication team will actively engage in adolescents and youths forums/sessions in order to strengthen the strategies for specific targeted key messages on healthy timing & spacing of pregnancies, delayed first pregnancies for adolescents and youths, and myths and beliefs related to side effects of family planning. The project will also complete the talking books (DigiSomo) training for three community units in Napak dispensary which will help to boost the dissemination of FP information and sensitization on availability and provision of FP services to clients referred from these community units.

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Adolescent and Youth FP Uptake in Turkana

116, 13%

Adolescent Family planning uptake 10-14 yrs 162, 17% Adolescent Family planning uptake 15-19 yrs

654, 70% Youth Family planning uptake 20-24 yrs

Figure 30: Uptake of family planning method among adolescent and youth in Turkana County

The project continued to build capacity for provision of reproductive health information while creating demand and strengthening referral to facilities. This was done at community level by CHVs and by health workers at health facilities. The uptake of FP services among this age group is influenced by the already known and existing rumors and misconceptions on FP, and the cultural barriers. But these are the factors that the project seeks to reduce and eliminate. There is significant increase in the uptake of Family Planning Method among Adolescents and Youth who are between the ages of 20-24 compared to those aged between 15-19 years as displayed in the pie chart above. The strategies used to reach youth and adolescents included the use of specific targeted key messages of delayed first pregnancy for adolescents, health timing & spacing of pregnancies, side effects and misconceptions being addressed and demystification of myths and misconceptions and Counselling for Continuation strategy (C4C). This is also attributed to the Adolescents & Youths leaders TOTs training done during the quarter under review in the directly supported sites/facilities and community units.

The project carried out community activities including the sensitization of caretakers of ‘raia’ girls in Loima on the needs of adolescents and youth FP& RH life skills in the integrated outreaches and other community outreaches, sensitization of religious leaders on GBV and A&Y health needs. These activities were carried out alongside the continued sensitization and follow-up of CHVs on adolescent package of care available in the health facilities during the monthly review meetings.

In the subsequent quarter, the project will continue to reach the adolescents and youth in and out of school with sexual and reproductive health information through the use of CHVs, religious leaders and TBCs. The project will also continue to capacity build health care workers in the provision of quality youth friendly services.

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Samburu County

To address teenage pregnancy and early marriages in the county, the project continued to engage and sensitize A&Ys through collaboration with other stakeholders during the National Menstrual Hygiene day where 688 (M=453:F=235) A&Ys were reached with Family planning, Female Genital cutting (FGC), STIs and accelerator behaviour change messages and also distributed with sanitary towels courtesy of the Gender department, Samburu County Figure 31: Sirata Day Mixed Secondary School issued with Sanitary Government. In the subsequent, towels courtesy CEC Gender and Samburu Girls Foundation quarter the project will focus on engaging more A&Ys both in and out of school with these messages using the already trained AYSRH Mentors. As shown by the pie chart below, 1,619 adolescents and youth received FP services. 70% were aged 20-24 years while 27% and 3 % were aged 15-19 and 10-14 respectively. Facility preparedness to respond to youth needs in a friendly and dignified manner will continue to be strethened through targeted mentorship and OJT on AYFS.

Adolescent and Youth FP Uptake in Samburu

52, 3%

Adolescent Family planning uptake 10- 439, 27% 14 yrs Adolescent Family planning uptake 15- 19 yrs Youth Family planning uptake 20-24 1128, 70% yrs

Figure 32: Uptake of family planning method among adolescent and youth in Samburu County

Couple Years of Protection (CYP):

During the reporting period, the project managed to achieve a CYP of 6,663 against the set quarterly target of 7311, an achievement of 91%. Table 16 below shows a snap shot of the achievements per Sub County.

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Table 15: Couple years of protection in Turkana and Samburu Turkana Samburu Samburu South Loima Kibish Turkana Central East Samburu Total CYP 1456 459 168 2083 2728 1852 4581 6663 Target 1729 555 342 2625 3809 877 4686 7311 % Achieved 84% 83% 49% 79% 72% 211% 98% 91%

Turkana County Generally, there was a drop of CYP for Turkana from 96% in Q2 to 79% in Q3 of 2019 although Turkana South reached twice as many clients as both Loima and Kibish sub counties in this reporting period. This was attributed to the free medical camp conducted with the support of the Ministry of Health, the County Government and other partners in May 2019. The project will continue to harness the multipronged approaches like HCWs mentorship, CHV sensitization on family planning and referral, data review and quality improvement learning techniques to increase acceptance of FP commodities. AFYA TIMIZA will also work with other partners and FBOs to leverage FP information sharing. CMEs on commodity management will continue to help check commodity stock outs. The project will continue engaging the trained youth leaders TOTs, trained religious leaders TOTs, CHVs, TBCs, facility in charges and other health care providers to conduct youth forums, utilize the talking books (DigiSomo) and education in order to provide FP key messages, referrals and linking of clients to health facilities for the FP services.

Samburu County: To improve CYP in the county, the project scaled up uptake of family planning services through a range of approaches that included hard to reach outreaches, facility in-reaches and UMATI outreach. The project also continued strengthening the availability of commodities by collaborating closely with Afya Ugavi to monitor stock outs as well as sensitize health care workers on commodity management and updating on stocks using a WhatsApp platform. To reduce discontinuation particularly for long term methods, the project conducted on job mentorship on counseling clients for continuation of methods. In subsequent quarter, the project will identify facilities with high discontinuation rates and conduct targeted mentorship of healthcare workers on counseling clients for continuation of methods. In addition, since misconception on side effects has been identified as a major contributing factor to discontinuation, community health workers in those specific areas will be engaged to conduct health education and address the misconception. At the community level, CHVs continued to refer clients for services as well as taking services to people through outreaches.

FP Commodity reporting:

AFYA TIMIZA continued to support facilities in the 5 sub counties to ensure timely reporting of FP commodities. As shown in Figure 33 below, the reporting rates were over 98.8% in all the sub counties.

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Facility Contraceptive Consumption Report and Request Form October 2018 to June 2019 Reporting Rate

Figure 33: Family planning commodity reporting rate trends by Sub-County

Turkana County There was improved coordination and collaboration between the project’s technical officers and facility in charges with other partners like Afya Ugavi and ministry of health through the SCHMT members who ensured timely reporting by all facilities offering the FP services in the sub counties. In order to maintain this reporting rate, the project will continue conducting supportive facility and facility data review meetings, OJTs and coaching on commodity management and reporting that will ensure reports are accurate and timely.

Samburu County: Timely reporting of family planning commodities is essential in ensuring adequate supply of family planning commodities hence reducing missed opportunities. AFYA TIMIZA during the quarter distributed reporting tools to facilities that did not have. In addition, through working closely with the sub county pharmacist, facilities that delayed reporting were noted and follow up made on time to ensure they reported. In subsequent quarter, the project will continue supporting the sub county pharmacist to take up the leading role in following up on commodity reports. To address data discrepancies of the reported data, the project engaged facility in-charges to verify FP data in the summaries and the ones captured in DHIS2. Gaps identified were addressed by the SCRHIO.

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C: NUTRITION

Iron and Folate Supplementation:

The performance of Iron and Folic Acid Supplementation (IFAS) indicator in both counties was impressive as the average coverage was above 80%. 17% of ANC clients were supplemented with iron tablets while 1% received folic acid. Details of the uptake by respective sub-counties is as depicted in Table 16 below.

Table 16: Uptake of Iron and Folate Supplementation by Pregnant Women (April - June 2019) Samburu Samburu Turkana Sub-county Kibish Loima Total Central East South Per Per Numb Perce Numb Perc Numb Perc Numb Num Num Perc cen cen er nt er ent er ent er ber ber ent t t ANC clients given combined iron & 4,015 90% 2154 61% 1436 99% 3,117 92% 3,114 76% 13,836 82% folate ANC client given 393 9% 1,338 38% 0% 247 7% 892 22% 2,870 17% iron - ANC clients given 55 1% 39 1% 18 1% 33 1% 71 2% 216 1% folate

Turkana County:

A total number of 13,836 pregnant women were supplemented with either combined IFAS, iron or folate during the reporting quarter. Of these, 7,667 (85.2%) received combined IFAS with Kibish (99%) reporting the highest number of women who were given the same. In order to achieve the desired coverage as well as encourage adoption of supplementation efforts by the target population, the project continued to use various avenues to reach out to pregnant women in the community. Among them, peer to peer approach through MtMSGs and rigorous education sessions, which were meant to enlighten the target population on the importance of ferrofolic acid and its role in preventing debilitating conditions like spinal bifida. Moreover, in collaboration with the community health component, there was a mapping exercise of pregnant women in different sub-counties who were closely followed-up and linked to respective CHVs for referrals to proximal health facilities. The contact was also used as an opportunity to ensure that these women received HIV Testing and Counselling Services (HTS) and enrolled for PMTCT, where applicable. Community members were further sensitized through talking books that highlighted key MIYCN messages in local languages.

As a way of sustaining recorded gains, county and sub county pharmacists will continue to be technically supported to promptly replenish stocks of combined IFAS while limiting iron supplementation to anemia cases only.

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Samburu County During the period under review, a total of 6169 (77.1%) pregnant women were supplemented with combined IFAS. Towards improving coverage, the project deployed different approaches such as engagement of CHVs and role models from Father-to-Father (FtFSGs) and MtMSGs who acted as mentors and support system to the pregnant mothers in their respective villages. Through health and nutrition education sessions, women of reproductive age group were further sensitized to diversify their diets through locally available food items while guided by the recommended ten food groups. Figure 34: Mothers listening to Digisomo Facility-based and hard to reach outreaches, together messages on IFAS during MtMSG monthly meeting with the Umati concept will continue to be utilized in achieving the desired coverage and outcomes in the county.

Deworming:

Turkana County:

Within the reporting quarter, a total number of 12,957 (101%) children were dewormed against a target of 12,806 (Table 18). A great improvement in coverage was recorded mainly because the project engaged county leadership through CHMT and SCHMT to enhance their capacity in use of HMIS tools to monitor and report coverage. Additionally, the project collaborated with key stakeholders: MoE, MoH and UNICEF, among others to ensure that all the 12-59 month old children were reached through different avenues. Deworming efforts were accompanied by improvement of access to potable water by working closely with Kenya RAPID, a USAID partner to leverage on their work in training of CHVs as well as provision of water treatment tablets.

Table 17: Number of Children Dewormed in Turkana De- Percent of Children wormed Estimated Population of Sub-County 12- 59 months de- 12-59 Children 12 - 59 months wormed Months Kibish Sub County 1,769 2445 72% Loima Sub County 3,492 4857 72% Turkana south Sub County 7,696 5504 140% Total 12957 12806 101%

Samburu County:

In Samburu County, the project collaborated with 100 CHVs to carry out a mobilization campaign that reached a total number of 46,859 under-fives through the deworming initiative in quarter three. Other platforms that were used to achieve optimal coverage were home to home/ECD supplementation and Malezi Bora national campaign.

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Exclusive Breastfeeding

Exclusive Breastfeeding Among New CWC Clients 8000 300%

7000 6717 243% 250% 6000 5178 200% 5000

4000 150% Percent

Number 3078 3000 2,495 2575 81% 103% 100% 1888 182297% 77% 2000 1269 949 50% 1000 769

0 0% Samburu Central Samburu East Kibish Loima Turkana South

CWC 0-59 new visit Exclusive breastfeeding 0-6 months Percent of new CWC clients exclusively breastfed

Figure 35: Number and Proportion of New CWC Children Exclusively Breastfed

Turkana County:

Figure 35 above indicates that 136% of new CWC clients between 0 to 6 months were exclusively breastfed, which is a positive indication that knowledge is being translated to practice by community members. This achievement was realized by closely engaging with HCWs to ensure that every contact made with pregnant and lactating women (PLWs) was maximized in consistently giving them key breastfeeding messages. Addressing misconceptions associated with breastfeeding and engagement of men as not only support system but also in active participants in RMNCAH and nutrition services went a long way in realizing the recorded gains. Through monthly household visits, which were conducted by CHVs to follow- up adoption of optimal Infant and Young Child Feeding (IYCF) practices, and peer to peer support, women were able to appropriately address any encountered challenges, which were associated with breastfeeding.

Samburu County:

The county recorded relatively good EBR based on Figure 34 above. 77% and 97% of infants aged between 0 to 6 months in Samburu Central and Samburu East, respectively were reported to be exclusively breastfed. This could be attributed to a strong support system through peer to peer approach whereby PLW walked the journey together in addressing common issues related to MIYCN. Women who had received key information on IYCF were encouraged to share the same with their peers towards creating a ripple effect and reaching masses. Positive indigenous knowledge around child care and feeding practices was tapped and packaged in a more comprehensible way to community members. For sustainability, the project worked closely with HCWs and CHVs to ensure that monthly feedback meetings were etched in the system to track progress in the implementation of BFCI activities.

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Management of Acute Malnutrition:

The general nutrition situation in Turkana and Samburu remained very critical probably due to long drought periods experienced during the quarter. According to data presented below (Figure 35), Moderate Acute Malnutrition (MAM) stood at 25.3% while Severe Acute Malnutrition (SAM) was 7.1%, bringing the Global Acute Malnutrition (GAM) rate to 32.4%. This level is way above the acceptable cut-off of 15% and below, and signifies an emergency situation.

MUAC Screening Results for Children Aged 6 – 59 Months at CWC (April- June 2019

Total 6,843 27,086 1,937

Turkana South 28%, 2,419 63%, 5,482 9%, 807

Loima 35%, 1,500 57%, 4,551 8%, 274

Kibish 30%, 1,881 63%, 2,696 8%, 550

Samburu East 29%, 260 65%, 3,436 6%, 87

Samburu Central 52%, 783 33%, 10,921 14%, 219

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

MUAC 6 - 59 months moderate (yellow) MUAC 6 - 59 months normal (green) MUAC 6 - 59 months severe (red)

Figure 36: MUAC Screening Results among Children Aged 6 – 59 Months at CWC

Turkana County:

Child malnutrition is quite prevalent in the county and a perennial problem. Out of the total number of under-fives (20,160) screened through the CWC within the quarter under review, 5,800 (28.7%) were moderately malnourished while 1,631 (8%) presented with severe malnutrition. Only 12,729 (63%) of the children were well nourished. Therefore, the global burden of malnutrition in Turkana County during the period under review was 36.7%, which meant that slightly over a third of the under-fives presented with some form of acute malnutrition. This rate almost compares with the results of a SMART survey, which was also done during the same quarter and unveiled GAM rates of 25.6%. It is within the reporting quarter that a serious drought was experienced, which resulted to a sharp rise in the number of malnourished children. Among other recurrent causes of malnutrition include food (poor breastfeeding and complementary feeding practices, consumption of limiting and non-nutritive foods, which is compounded by cultural beliefs and intra household food distribution), care (women workload, responsive feeding and psychosocial stimulation) and health (poor health seeking behavior and limited maternal and child care services). Furthermore, structural inadequacies have continued to play a role in recurrent nutrition issues. While appreciating that there is need for collective action to sustainably address food and nutrition security issues by nipping the problem from the bud, the project continued to work

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closely with the county to initiate the process of having a County Nutrition Action Plan (CNAP) that embraces multi-sectoral programming. This is in addition to working with policy influencers to ensure that explicit resources are set aside for nutrition interventions. At the community level, there has been a deliberate effort towards empowering women and men to have a source of income that can sustain access to and utilization of nutritious, diverse

Figure 37: A group of MtMSG members venturing into food production through use of DTCs to enhance dietary diversity as well as generate income from sale of extra produce and safe food items. Figure 38 below confirms innovations that were supported by the project towards achieving sustainable gains in health and nutrition outcomes. The MtMSG from Katilu grows Drought Tolerant Crops (DTCs) that easily adapts to water and heat stress while at the same time giving higher yields as opposed to the traditional ones. Also, some MtMSGs from Turkwell have been supported to initiate fruit and vegetable gardens by river Turkwell towards enhancing dietary diversification. The plan is to tap into indigenous knowledge so as to promote food preservation and storage to ensure availability of nutritious, safe and diversified foods throughout the seasons. As an immediate response to the high malnutrition levels, and in order to avert any possible mortalities, the project collaborated with the county government and other stakeholders to support an integrated health and nutrition outreach model in Turkana South. A total of 20 hotspots were identified and supported in carrying out rigorous case finding through continuous MUAC screening among all the under-fives for a period of 3 months.

Samburu County

With reference to Figure 35 above, the rates of malnutrition during the reporting period in Samburu County were computed using data for a total number of 15,706 under-fives from CWC. The results were not alarming as SAM stood at 306 (1.9%) while MAM was 1,043 (6.6%). A total of 14,357 (91.4%) under-fives were of good nutritional status. In order to promote sequencing, integration and layering, Afya Timiza continued to collaborate with NHP plus to ensure active case finding and referral through CHUs and ECD centers. Besides, the project worked closely with community structures through CHVs and MtMSGs to sensitize members on various enterprises that can form a basis for IGAs, and sunken/vertical vegetable gardens (figure 37) that can greatly enhance food availability and accessibility, thus positively influencing child feeding practices. Child nutrition in the county was also enhanced through food preparation demonstration sessions (figure 38) that were meant demystify lowly regarded but highly nutritious food items like sorghum, which is readily available in the county. The regular demonstration sessions were conducted in collaboration with the MoALFI.

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Figure 38: Sunken and vertical vegetable gardens at household level s

Figure 39: Food preparation demonstration sessions

Vitamin A Supplementation:

Table 18: Vitamin A Coverage and Uptake Estimated Vitamin Vitamin A Vitamin A Vitami Populatio A Performanc County Supplementatio n A n 0 - 59 Coverag e against n Target months e Target Turkana South 11,697 27,699 42% 3,929 298% Loima 3,605 24,440 15% 3,318 109% Kibish 1,900 12,302 15% 1,344 141% 17,202 64,441 27% 8,591 200%

Turkana County:

In the quarter under review, 17,202 children aged between 6-59 months received vitamin A supplementation. Turkana south overachieved by 298% while Kibish and Loima followed at 141% and 109%, respectively. Overall coverage, against county targets remained below desired coverage. This continued to be addressed through engagement meetings with County nutritionist, public health officer, public health nurse coordinators and SCHMT so as to offer leadership and coordinate HCWs, together with teachers in improving documentation and reporting.

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Also, within the quarter under review, the project provided technical assistance in planning activities to commemorate Malezi Bora week, towards upscaling provision of MIYCN services to the under-fives and PLW.

Samburu County: In an effort to further improve vitamin A supplementation coverage, the project worked closely with key line ministries: MoH, MoE and MoALFI to upscale provision of vitamin A to school going children as well as the target population within the reporting quarter. Additionally, a range of other MIYCN services were offered during the Malezi Bora week.

Figure 40: Vitamin A supplementation by CHVs at an ECD center

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D: WATER SANITATION AND HYGIENE (WASH)

Turkana County: Progress Community Led Total Sanitation (CLTS) Implementation During the quarter, continuous follow ups were conducted on the triggered villages of Nakwakipi and Lowaidapal in Turkana south. This was done by a team of CHVs and CHEWs who have been trained on WASH technical modules and CLTS implementation procedures. The Sub County Public Health Officers provided oversight to ensure quality of the WASH structures (pit latrines, tippy taps, refuse pits, dish racks and cloth lines) based on PHE model that were installed at the household as per the CLTS implementation guidelines. The two villages have reached CLAIM stage where all the households have dug and constructed the pit latrines and installed the other WASH structures in readiness for verification and certification to ODF by a team of independent verifiers/ certifiers constituted by the County Public Health Officer as per the CLTS implementation guidelines (See table 21).

Table 19: Progress on triggered villages towards ODF status in Turkana South # Name of Location # of # of latrines Status # of people Male Female village Latrines remaining benefiting done 1 Lowaidapal T. south 39 0 Claim 234 129 105 Stage

2 Nakwakipi T. south 45 0 Claim 270 149 121 Stage

TOTALS 504 278 221

To ensure sustainability, 4 CHVs and 2 CHEWs in Turkana South have been capacity built on how to trigger villages and do follow ups through claim, verification and certification stages to achieve ODF status as per the CLTS guidelines with minimum supervision. Samburu County Collaboration with Partners 1. Feed The Children- AFYA TIMIZA partnered with Feed the Children to design a 25000m3 earth pan for the community in Kiltamany CU Samburu East. This project is located in one AFYA TIMIZA hard to reach outreach sites in Samburu East and it will provide water to the surrounding community including a primary school and a dispensary with an estimated population of about 3000 people. Feed the Children will fund the construction of the earth pan while AFYA TIMIZA and the Sub County Department of Water will provide technical assistance in supervising construction of the pan for quality assurance. 2. Amref Trachoma Project-Trachoma is a contagious bacterial infection which affects the conjunctival covering of the eye, the cornea, and the eyelids. It is often associated with poverty and lack of proper hygiene. Amref Trachoma Project in collaboration with the Ministry of Health have been implementing a comprehensive and integrated Trachoma control programs since 2001 with a goal to contribute towards poverty alleviation and disability reduction through the management of this

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major blinding disease with target direct beneficiary of 110,000 people annually. One of the activities towards this intervention is the construction of 12 bed capacity model eye care inpatient ward at Maralal County referral Hospital and AFYA TIMIZA partnered with the County Public Health officers in the planning, design and production of BOQs for the ward. Trachoma Project will fund the construction works will AFYA TIMIZA and County Public Health office will provide TA on supervision of the construction.

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E. HEALTH SYSTEMS STRENGTHENING

E.1 Leadership Management and Governance To remain on the self-reliance path and promote commitment in county health leadership, management and governance, AFYA TIMIZA engaged AMREF’s Institute for Capacity Development (ICD) to train 28 health facility management committees (HFMCs) in Turkana County on corporate governance and understanding the budgeting and planning process. Moreover, 26 facility in-charges in Loima, Kibish and Turkana South Sub-Counties underwent similar training to build on their knowledge and skills for effective leadership management and governance of resources and enhanced service delivery within a level two and three facilities. Leadership Management and Governance is one of the key pillars of an effective health system and as such the HFMCs have the responsibility of overseeing the preparation and implementation of facility work plans, supervision and control of all resources entrusted the health facilities. The training is expected to enhance HFMCs oversight role for the management of resources in the health facilities, accountability, transparency and efficiency in the use of financial and other resources, data use for decision making, programme improvement, resource mobilization and oversight as well as review of regulations governing the management of health facility resources and services. In quarter 4, the project will roll out similar trainings in Samburu County.

Figure 41 Training session at Kaikor Sub-County Hospital E.2 Policy, Planning and budgeting

To address lack of linkages between budgetary allocations and sector priorities identified during the health sector performance review, AFYA TIMIZA sensitized the CDOH in both counties on the need to implement major health systems reforms aimed at improving resource priority setting, planning and budgeting, including the involvement of communities in planning and budgeting decision‐making. To achieve this, the project supported the two CDOH to develop County Health Sector Strategic and Investment Plans with clear priority objectives and targets that ensures a clear linkage between the strategic priority objectives identified in the sector strategic plan with the annual program based budgetary allocations within the CDOH. The project supported the CDOH leadership to participate in the 4th Annual Legislative Summit in Kisumu where Amref was a panel speaker during the general session on “legislation supporting the realization of universal health coverage.” The session addressed the need for health professionals to engage more in legal and legislative reforms to create sustainable transformation of the health system, the need to review The Public Procurement and Asset Disposal Act, 2015 to allow KEMSA to directly negotiate with manufacturers to enhance access to health commodities at lower prices and leverage economies of scale, and finally the need to review the Public Finance Management Act, 2012 to allow public health facilities to

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receive and retain funds directly for services provided. These are some of the policy interventions that would guarantee sustainability and self-reliance by counties. To strengthen the policy environment and increase county government, Samburu County enacted the county health services act. This act provides for CDOH commitment and enhances geographical access - a key component in UHC by establishing at least one health center in each ward (Art. 8 (1) c). Further it provides for citizen accountability and advocacy work by reaffirming that every person has a right to highest attainable standard of health (Art. 20 (1) a); strengthens investment in primary health care in affirming that the community unit, dispensary and health center is the basic unit of health (Art. 25 (1); provides for ring-fencing of health sector resources which is a key component of Facility Improvement Fund (Art. 42 (2) (a & b); guarantees constant, adequate and quality essential medical supplies in all health facilities (Art. 36 (a & c) and; classifies county hospital as a procuring entity (Art. 43 (2

In response to the Organizational Capacity Assessment (OCA) findings that both the Medium Term Expenditure Framework (MTEF) and AWP process was heavily “top‐down” with reluctance of county level decision makers to undertake genuine consultation in decision‐making within the planning process. Afya Timiza utilized the Social Accountability Framework to sensitize 28 Community Health Communities (CHCs) and other community based organizations (CBOs) on the importance of public participation and bottom-up planning process. This push will make it easy for peripheral facilities to plan for identified local priorities by engaging communities. In the subsequent quarter, the project will continue to sensitize the CDOH on the AWP process and cycle which begins in November each year. The project will also support the CDOH to convene the AWP review meeting where the health sector will identify the priorities for the subsequent year. This is planned to coincide with the treasury releasing the Budget Outlook Paper that elaborates the respective sector budgetary ceilings. This will help the CDOH to use identified priorities from the AWP review to bid for resources at the hearings in the Sector Working Group then prepare AWP planning tools, guidelines and resource envelopes for planning units, based on the indicative government resources allocated from the Sector Working Group hearings and declared resources from partners.

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E.3 Health Care Financing

To address financial barriers to access as well as catastrophic expenditure on health for communities in hard-to-reach areas, Afya Timiza continued to engage and facilitate NHIF officers in Samburu County to sensitize communities on the need for health insurance and also accredit health facilities. To date, 60 out of 95 public health facilities as well as 6 private health facilities in Samburu County have been accredited by NHIF to provide Linda Mama services. The accreditation process in preceded by some level of investment in infrastructural and human resources by the county government to enhance access, coverage and quality.

In Turkana County, Afya Timiza continued to spearhead the development of a health financing strategy and engaging in discussions to develop a UHC framework and road map that suits the unique needs of the agro-pastoral residents. The CDOH garnered the political support by the Governor and the recently enacted Community Health Services Act to ensure that UHC is rolled out in the county. The UHC framework as well as the health financing strategy stresses the need for public investment in health as a sustainable way of ensuring CDOHs journey to self-reliance.

During the quarter, Afya Timiza supported Turkana CDOH officers to participate in the 3rd National UHC Conference in Kisumu, where the team presented abstracts on among other areas; Experience sharing on implementation of Kenya's UHC model; Sustainable Financing and Budget Efficiency key towards Universal Health Coverage: Experience from Turkana County; Referral services and role of health specialist in UHC delivery, Community Health Strategy Approaches and Human Resource for Health Approaches in marginalized counties.

E.4 Health Sector Coordination

During the quarter, the CDOH continued to implement the tripartite engagement frameworks developed with Afya Timiza support on health sector collaborations. Specifically, the project together with World Bank supported the CDOH to convene a roundtable to adopt Terms of Reference for the County Health Stakeholder Forum (CHSF) that has been in place but operating without clear guidelines. The CHSF brings together all stakeholders that support health service delivery in the county and aims at enhancing leadership and coordination of health services among different partners for better health outcomes. The CHSF through technical support from the project adopted a sector‐wide approach (SWA) for joint planning, financing, implementing and monitoring of the AWPs. To emphasize the commitment to the SWA principles by partners, a code of regulation and conduct has been developed and is to be signed by all key actors in the health sector.

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E.5 Human Resource for Health

To facilitate and improve HRH functions, the project supported Samburu County to establish the Departmental Human Resource Management Committee (DHRMC) and their respective sub-committees which include training committees, recruitment committees, and performance management committees. The committee members have been identified and formally appointed by the county government. In the subsequent quarter, the project will support the induction of the DHRMC and support them to utilize the iHRIS system in collaboration with the HRH National Mechanism. This will build on the iHRIS training and use interfaces that were conducted in previous years. In order to increase the availability of FP/RMNCAH services that are expected to enable the counties to have a talent pool with experienced, qualified and skilled HWs for sustainable future full time employment, the projected signed a letter of agreement with Turkana County where project will implement a donor supported facility based contracted health workers program in the Turkana so as to address the HRH gaps as the counties are challenged by limited recruitment resources. Thereafter, the county government will absorb the health workers in line with the national health worker contracting guidelines. In the coming quarter, through the County Public Service Boards, the project will support the recruitment of 28 nurses 31 Community Health Promoters. It is anticipated that their presence in the sub counties will ensure that health facilities remain open and outreach services are offered routinely. IN the subsequent quarter the project will sign a letter of agreement with Samburu County to implement a donor supported facility based contracted health workers program in the county. To improve on the current knowledge and skills of the health workers, the project through county ToT’s and mentors supported trainings that addressed skills gaps for Health Workers in delivery of FP/RMNCAH, Nutrition and WASH services in Samburu and Turkana counties. The trained number is 275 in both counties. These included 194 CHVs, 40 Adolescent and Youth mentors and 41 health facility based staff. The training data was scheduled and updated into the iHRIS train. In the subsequent quarter, the project will continue with the partnership with Kenyatta University and county based ToTs to address current gaps in the HWs training needs through the High Impact Intervention (HII) training using skills approaches in Samburu and Turkana counties. Table 20: Number of Health Workers Trained In Turkana County S/NO Training Course #Trained #Trained TOTAL (MALE) (FEMALE) 1. FP/RMNCAH & WASH Training 45 52 97 modules (CHVs) 2. Ushujaa Digisomo Training for 45 52 97 CHVs Total 90 104 194

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Table 21: Number of Health Workers Trained In Samburu County S/NO Training Course #Trained #Trained TOTAL (Male) (Female) 1. A&Y Mentors Training on 14 26 40 Digisomo 2. KQMH 7 11 18 3. SGBV & Gender Integration 13 10 23 (ToT) Course Total 34 47 81

E.6 Supply Chain Systems In order to strengthen quality improvement in supply chain management in Samburu County, AFYA TIMIZA collaborated with AFYA UGAVI to mentor and coach 28 health workers in the three sub counties on continuous Quality Improvement in quantification, forecasting and general commodity management.

AFYA TIMIZA provided, technical, logistical support to ensure that participants were mentored and coached on quality improvement in supply chain framework, on how to use, select, procure and distribute commodities, rationale for forecasting and supply planning, and forecasting methodologies.This included training on 5S principles in commodity management, and quality improvement tools for abstraction, understanding processes, analyzing and displaying data, and organizing ideas in supply chain. The training provided health care workers with knowledge and skills in documentation to better capture commodity data for decision making using QI tools in line with the Kenya Quality Model for Health.

E.7 Strengthening the Quality of Health Service Delivery

In order to sustainably increase knowledge and skills of health care workers in Samburu and Turkana to provide quality FP/RMNCAH and Nutrition high impact interventions in line with J2SR, AFYA Timiza provided technical support to the CDOH supported mentorship sessions in Samburu East. Subsequently, 25 HCWs were mentored on QI approaches to address the following gaps in across 6 health facilities in Samburu East and 1 facility in Samburu Central: Accurate and complete partographs, syphilis testing in ANC and administration of oxytocin within 1 minute of birth. Further, in order to establish a sustainable mentorship programme, the county QI department focal person was mentored on drafting proposal to the CDOH to support QI mentorship. Subsequently, the CDOH committed to supporting mentorship across 6 health facilities in Samburu North and 6 in Samburu East. During the quarter the project also provided technical and logistical support for mentorship on QI to 27 HCWs across 9 health facilities in Turkana South and Kibish Sub-Counties) specifically the project supported baseline assessments in selected process indicators to help identify gaps for QI action. Facilities were given QI support in 5s and improvement of work processes. To operationalize the mentorship programme in line with MOH Mentorship Guidelines 2018 and enhance the competencies of mentees in FP/RMNCAH, Nutrition and WASH, Afya Timiza will continue to give technical and logistical support to the CDOH for Post-training Follow-up and individualized facility based Mentorship and coaching program, including mentorship evaluation in line with the Afya Timiza Mentorship Implementation framework.

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Figure 42: Progress on Implementation of AFYA Timiza Mentorship and Coaching Program

In subsequent quarters, AFYA Timiza will continue to seek commitments through engagements with CDOH and other stakeholders to enhance sustainability of the QI and mentorship initiatives.

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SUB-PURPOSE 2: INCREASED CARE-SEEKING AND HEALTH PROMOTING BEHAVIOR During the quarter, AFYA TIMIZA intensified Message dissemination for caregivers and social influencers, in addition to A&Y activity implementation. The project was able to disseminate messages to 47,844 (M: 16, 826, F: 31,018) caregivers and influencers and 7,879 A&Y (M: 3,651, F: 4,228) Adolescents and Youth (A&Y). In partnership with the Ministry of health and other stakeholders; Trained 66 (M:43,F:23) community health volunteers (CHVs) and 4 CHEWS (M:3,F:1) on FP/RMNCAH, WASH and Nutrition modules as well as use of Digisomo reaching 46,988 (M: 16,044, F: 30,944) beneficiaries, in 5 Sub Counties. The project scaled up peer to peer approaches through trained A&Y mentors, who were able to reach 3,312 (M: 1, 366, F: 1,946) beneficiaries. Activity Males Females Totals Digisomo/Ushujaa 16,044 30,944 46,988 CHV Training-Ushujaa 43 23 66 CHEWs Training -Ushujaa 3 1 4 Care Givers & Traditional leaders 67 0 67 Influencers Beneficiaries reached through peer group sessions (M2M chamas, F2F, men groups - 669 50 719 tree of men) Sub-Totals 16,826 31,018 47,844 Total Care Givers & Influencers 47,844 10-14 years 480 870 15-19 years 1,643 1,605 A &Y 20-24 years 1,528 1,753 Sub-Totals 3,651 4,228 Total A&Y 7,879

OUTPUT 2.1: INCREASED KNOWLEDGE AND DEMAND FOR FP/RMNCAH SERVICES

Scaling up peer to peer approaches for caregivers and influencers

The project continued to scale up peer-to-peer approaches and supported CHVs to conduct health education at community and facility levels through dissemination of FP/RMNCAH, WASH and Nutrition messages. The sessions were conducted in mother and father groups, community barazas and outreaches, facility health talks, tree of men model among others.

AFYA TIMIZA supported integrated outreaches in the health facilities and the community to increase demand and Figure 43 Sensitization of caregivers’ session at Kaitese in Loima Sub County uptake of FPRMNCAH, Nutrition and WASH services. The outreaches were carried out by CHVs and Health Facility Workers (HCW) using the Digisomo, Ushujaa booklets and CHV guides, thereby sensitizing 46,988 (M: 16,044, F: 30,944) beneficiaries

Figure 44: Session of traditional leader – Emurons engagement at Lochwaa

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Additionally, the project continued to involve and engage men and traditional leaders as a way of shifting community norms. 5 Emurons (Traditional seers), 2 cabinet members to the Emuron and 60 (M) Kraal leaders were sensitized on FPRMNCAH leading to mobilization and sensitization of 719 (M:669, F:50) beneficiaries through Ekitoe angikiliok (tree of men) in Liam and Turkana South Sub Counties. In Samburu, the project reached 768 fathers/caregivers who are also traditional elders through the CHVs through their community education sessions/meetings that include father groups and Barazas. In total 1,504 men were engaged and sensitized on FPRMNCAH. As a way of promoting interpersonal communication as well as responsive and sensitive care the project trained 4 CHEWs (M:3, F: 1) and 66 CHVs (M: 43, F: 23) on the five project module FP / RMNCAH, WASH and Nutrition, use of Digisomo to effectively deliver the same messages to the community and quality reporting using M&E tools. The participants were also provided with Ushujaa communication kit that contained a Digisomo [Talking book], Figure 45: CHVs pause for a photo after Ushujaa flip chart and Mama and Baba Shujaa booklets. Project completing the training on Digisomo thematic areas integration was facilitated with CHVs also sensitized on A&Y SRHR, Youth Friendly Services (YFS) and (S) GBV. CHV feedback meetings: The project supported the feedback sessions in 6 CUs; Lderkesi, Ngutuk Eng’iron, Lorubae, Sere Olipi, Scouts and Swari. Usage statistics were extracted from 36 Talking books. The CHVs and scouts from these sites were sensitized on MOH 100, effective referral and addressing usage and maintenance of Talking books while promoting adequate coverage of all health pillars of FP//RMNCAH, WASH and Nutrition messages. Accurate recording of data using the tools was emphasized.

Figure 46: Feedback meetings in Swari and Lorubae

Digisomo beneficiary’s database: A total of 33,476 beneficiaries have been reached with messages from Digisomo. This is analysis for a period covering September 2018 to April 2019. The table below details the population reached and the counties of reach:

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Digisomo Beneficiaries Sept 2018- Apr 2019 30,000 25,000 20,000 15,000 10,000

# beneficiaries # 5,000 0 Women Pregnant Breastfeedi Social with child Men Others Total women ng women influencers <5 years Turkana 5,009 7,981 9,224 163 5,521 56 27,995 Samburu 613 1271 1866 586 890 255 5,481 Figure 47: Digisomo beneficiaries (Sept 2018- Apr 2019)

PIMA TOTOs Infant feeding bowl: A total of 36 Pima Toto Feeding Bowls were distributed to 30 mothers who are members of Community Mother Support Groups in Loikas CU, whilst 6 of the Bowls were allocated to the County Referral Hospital’s Nutrition department wing for demonstration purposes targeting care givers who visit the nutrition clinic and for use in the pediatric ward. The purpose of the bowls is to enhance better nutritional practices in food uptake. 2.2 INCREASED CARE-SEEKING AND HEALTH PROMOTING BEHAVIOUR AMONG ADOLESCENT AND YOUTH Strengthen the coordination of FP/RMNCAH SBCC among A&Y During the quarter, the project participated in a workshop on Adolescent & Youth [A&Y] meaningful engagement score card with the main agenda being developing a roadmap to formulate the Youth and Anti-beading policies as well as the establishment of the Youth Advisory Council [YAC] in Samburu. The Key stakeholders engaged in this process included County Gender department, Youth and Sports office, Education department, Health department, County Assembly, County Executive, Youth Development and Enterprise Fund, Samburu Women Trust, Samburu Girl Foundation, Y-Act and A&Y representatives. The team developed a clear roadmap in developing the two policies for the County under the stewardship of the County Department of Gender, Youth and Sports. In the same breadth, an interim YAC was also coined from the team and will have its first sitting next quarter to review the draft TOR and start the process of selecting the County YAC members. The project participated and offered technical support in the Turkana County Quarterly Review meeting held from 8th – 10th of May 2019 at Black Gold Hotel in Lokichar. The A&Y SBCC officer took the CHMT & SCHMT officials as well as other NGO partners in attendance through the AFYA TIMIZA A&Y IEC developed materials and received expression of interest form partners who wanted their project-related messages to be put on the posters, such as messages on Figure 48: AFYA TIMIZA Officer presenting HIV and TB prevention. during the County QRM in Lokichar

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Additionally, advocacy follow up meetings for A&Y was held with the CDGYS and CDoH to concretize formation of the YAC was conducted in Samburu. The team agreed on a list of key A&Y interest stakeholders to be engaged in the first YAC meeting. This include but not limited to CE, CA, CDoYS, CDoH, CDoE, Children’s’ department, SWT, SGF, YEDF, Y-Act, Afya Timiza and Youth representatives. This forum will be optimized as the main advocacy platform to ensure finalization and adoption of Samburu County Youth and Anti beading policies. Additionally, A & Y Leadership planning meeting was held in Kanaodon CU of Turkana South Sub County, where 11 youth leaders representing 8 community groups (2 Kanaodon poultry keepers, Kanaodon Bee keepers, Kanaodon Young farmers group, Kanaodon football team, Kanaodon dancing group (1 Female and 1 for males) and Boda boda group) were in attendance. The meeting’s agenda was to plan FP outreaches as well as integrated outreaches during Edong’a dances. A total of 32 A&Y Figure 49: Kanaodon CU Adolescent & (22males and 10 females) were sensitized on SHR among Youths community group leaders planning meeting held outside one of the churches them 11 officials of the 8 groups. in Kanaodon

Dissemination of IEC/BCC materials to increase knowledge among the A&Y During the quarter, the project produced materials in print [kijana mchangamfu and msichana mchangamfu booklets plus thematic posters] and audio [radio dramas and spots]. These materials and messages were disseminated among 35 A&Y interest stakeholder representatives during A&Y forum on policy formulation. Further to this, trained A & Y mentors were trained on use of these materials and will be engaged in Figure 50: A & Y on gallery walk on dissemination of the same in all available opportunities. Mainyotto messages and materials Materials distributed were 300 kijana and msichana mchangamfu booklets. To scale up peer to peer approaches among the A&Y, AFYA TIMIZA used various approaches to disseminate comprehensive Sexual Reproductive Health (SRH) messaging reaching a total of 7,879 A&Y (M: 3,651, F: 4,228). Participants were equipped with knowledge on ASRH and life skills as well their capacity enhanced on social mobilization. In Samburu 30 A&Y mentors were trained on use of Digisomo with A&Y thematic messages in a two-day training led by the CHMT in Archers, Wamba and Maralal. The participants were drawn from A&Y specific cohorts of Binti shujaas, morans and In-school Figure 51: A & Y mentors learning how to use Digisomo talking youth. A&Y mentors who were non-CHVs books and successfully completed the training were assimilated in the community units in their areas and will be the A&Y representatives in the CHUs. A&Y reached during this quarter has been segregated in the tables below.

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Turkana A & Y reach

10 – 14 15 – 19 20 – 24 TOTAL Overall Male Female Male Female Male Female Male Female TOTAL Health education in 73 226 608 680 1084 1086 1299 2539 3838 households by CHVs Peer to peer sessions 208 364 318 496 312 546 838 1406 2244 by Mentors TOTAL REACH 281 590 926 1176 1396 1632 2,603 3,398 6,001

Samburu A & Y reach

10 – 14 15 – 19 20 – 24 TOTAL Overall Male Female Male Female Male Female Male Female TOTAL Health education in in 61 56 438 216 21 18 520 290 810 school A&Y Peer to peer sessions 138 224 279 213 111 103 528 540 1,068 by Mentors TOTAL REACH 199 280 717 429 132 121 1,048 830 1,878

During the quarter, the project also held A&Y sensitization meetings for caregivers and fathers of raia (rural youths) girls in three CUs in Loima SC reaching 240 caregivers (M: 72, F: 138). A total of 7 Binti Shujaa were reached at Kang’akipur health facility in Turkana with FP messages during their Post Natal Visits (PNC) as show in the below figure

Figure 52: Binti Shujaas at Kang'akipur Health Centre

Improving Menstrual Management Under the stewardship of the County Gender department, the CDoH and CDoE, the project participated in an event to mark Menstrual Health/Hygiene Day celebration. This event was held in Kisima and Sirata mixed secondary school in Samburu Central reaching a total of 477 (M: 346; F: 131) and 136 (M: 67; F: 69) A&Y reached respectively. Health education tool center stage with emphasis on menstrual Figure 53: CEC Gender and Youth health, preventing teenage pregnancy, drug abuse and A&Y mentoring Sirata Secondary School students during menstrual hygiene day retention is school. The schools received donation of celebrations sanitary pads from the CDoG and Afya Timiza committing to support school health club activities especially on ASRH thereafter.

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Strategic Partnership and collaboration

During the quarter, the project ensured consistent service availability and improved quality of care for A & Y at health facilities by supporting sensitization of 44 HCW (13 from Loima – Lokiriama, Turkwel, Kopeeto and Lorugum facilities and 31 from Turkana South - Locheremoit, Lochwaa, Kang’akipur, Lope rot, Kanaodon, Lokapel, GoK and RCA Lokichar and Nakabosan facilities were sensitized during the monthly review meetings. A follow up on uptake of A&Y service uptake and scale up was discussed during the meetings. The project partnered with Youth in Action and Samburu Women Trust in developing the Youth and Anti beading policies as well as giving technical support to CDoGYS and CDoH to establish the YAC. Several meetings have been held with these teams and other stakeholders with the draft Anti beading policy already in place and draft Tour for YAC awaiting review and endorsement in the next meeting/ quarter. Further to this, in efforts to widen reach of the A&Y interventions, the project is working on strengthening collaboration with Serian FM and LET Youth theatre group. The approach will have in-school and community sessions dubbed vijana tuchangamke / tuchapiane respectively that will be aired live through Serian FM radio. Vijana tuchangamke na tuchapiane mtaani will also have feature stories recorded and aired during specific A&Y focused programs in the same radio station. This will have more A&Y reached with messages and linked to ASRH services in a large scale across the County.

Interreligious leaders’ engagement for increased care-seeking and health promoting behavior for FP/RMNCAH Nutrition and WASH services During the reporting period AFYA TIMIZA supported 7 (5M; 2F) members of Samburu Inter- Faith Network and 6 representatives of the County social sector heads (health, education and water) as well 2 County economic budget and planning department’s representatives to conduct a Social Intelligence Reporting (SIR)in view of gaps identification in service delivery. The teams collected information and evidence on service provision in three health facilities that is; Lkiloriti Dispensary, Sirata Oirobi Dispensary and Longewan Dispensary, three schools: i.e. Lkiloriti Primary School, Oirobi Primary School and Longewan Primary School and in three water point;, Lkiloriti water point, Sirata water point and Longewan water points to gather information on FP/RMNCAH, Nutrition and WASH services delivery in these facilities as well as how funds allocated are being utilized. Figure 54: Data collection during social intelligence reporting conducted at The team was also supported to conduct follow up on the Lkiloriti Dispensary previously conducted SIR in Kisima, Maralal and Loosuk facilities. It was noted that most of the gaps previously identified had been addressed. The report generated from the activity will be shared with the County Government among other stakeholders to address the gaps identifies as well as the Religious Leaders who use it to advocate for closing of the gaps through budgetary allocation and change of attitude among duty bearers. The project also offered support, supervision and mentorship to 5 (3M: 2F) Religious Leaders and 10 (6M: 4F) Religious Youths to attend and participate in the EAK youth weekend challenge that was held at AIC Church- Archers Post with the focus of holding inter- faith congregational level dialogues session on health services as well as disseminating messages and creating awareness on FP/RMNCAH, WASH and Nutrition services.The

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trained TOTs disseminated health messages to over 70 ( youths who attended the weekend challenge During the event, the project supported department of health to integrate health services by the among the services provided included HIV testing, Blood Pressure screening and Health education. At least 30 youths were tested on HIV. From the activity, it was noted that there is need for continuous interaction with the youths as there exist a myriad of myths and misconceptions that hinder them from accessing health services especially those related to family planning HIV and AIDS due to related stigma and discrimination that comes with it.

Additionally, during the same period the project integrated health service provision including cervical cancer screening to the Islamic community at Jamia Mosque-Maralal in Samburu Central. The Muslim ToTs and peer educators mobilized their congregants who turned out in good numbers. Some of the health services provided include; Screening (Nutrition, BP and Diabetes), Figure 55: Sensitization of Islamic Immunization of children, Deworming and Vitamin A women on cervical cancer provision, Growth monitoring and Health education among others. During the reporting report, through AFYA TIMIZA, IRCK supported the Turkana Interfaith Network to conduct SIR in Turkana South Sub-County. The process collected information and evidence from 5 health facilities, 5 water points and 5 schools spread across Kanaodon, Locales, Locheremoit, Napusimoru and Kang’akipur communities. The information collected will be compiled into a report that shall be disseminated to claim holders, duty bearers and other partners to enable them make informed decisions including financing for health. Review of the ‘Faith for Life’ booklet: Informed by the demand for the project to continue disseminating up to date information and use of more simplified pictorial Faith for Life job aids to unreached congregations for improved health seeking behaviors and practices, the project supported the review of Faith for Life Handbook and now awaits validation in August 2019.

OUTPUT 2.3: IMPROVED GENDER NORMS AND SOCIOCULTURAL PRACTICES

Provision of gender-equitable FP, RH, MNCAH and nutrition services During the reporting period, the project offered technical support to County departments of health and gender in Samburu County in planning and commemoration of Menstrual Hygiene Day with an objective to promote gender equitable reproductive health services among adolescents and youth. The theme of the year’s celebration was- “No more limits- Empowering women and Girls through Menstrual Hygiene’’. Sensitizations on sexual reproductive health, menstruation stereotypes, harmful gender norms and distribution of sanitary towels was facilitated. A total of 613 (M-415, F-198) students and teachers were sensitized on menstrual hygiene and sanitary towels distributed.

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Figure 56: Menstrual hygiene day celebration in Kisima and Sirata Secondary Schools In addition, the project supported gender integration in leadership governance and management training for Facility Health Management teams and Community health committees in Turkana County. The objective was to equip the participants with knowledge on gender sensitive planning, budgeting, monitoring and evaluation for improved FP/RMNCAH, Nutrition and WASH. A total of 159 (M- F-) participants were sensitized. Gender policy and strategy development The project offered technical support to County departments of health and gender in Samburu for during stakeholders’ anti-beading policy development and gender policy review forum. The objective of the forum was to have buy in and ownership by the county government and stakeholders of ant-beading policy while for gender policy review was to in cooperate feedback as a follow up of a review at departmental. During the forum, 36(M-19, F-17) participants were in attendance. Figure 57: Stakeholders’ forum during A framework for anti- beading policy was developed and Gender Policies review forum in Samburu inputs on the gender policy incorporated awaiting County validation by the multi-sectorial team. In the subsequent quarter, the project working with departments of gender, health, Y-Act and other stakeholders will continue to offer technical support gender policy validation and anti-beading policy development. Comprehensive post GBV care During the quarter, the project supported training of health care workers on Gender Integration and clinical management of Sexual and Gender Based Violence with an aim to equip them with knowledge, skills, and attitudes on gender sensitive normative care and post GBV Figure 58: Gender integration and Clinical management of SGBV care. In attendance were 26(M-15, F- in Samburu County 11) participants of varying cadres. The participants are expected to cascade the information through sensitizations and mentorships to enhance skills sets in gender integration and Post GBV care in FP/RMNCAH

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Post gender based violence care

During the quarter, sexual gender based violence prevention and response was integrated and a total of nine survivors were seen and offered post GBV Care as indicated in the table below;

Table 22: Survivors attended to April- June 2019 quarter and offered post GBV care in Samburu and Turkana Counties-Source: KHIS 2019 Samburu County Turkana County Total Indicators 0-9 10-17 18-49 0- 10-17 yrs. yrs. yrs. 9yrs yrs. 18-49 yrs. No. of survivors seen 0 1 1 1 3 3 9 No. reporting within 72hours 0 1 1 1 2 3 8 No. of PEP 0 1 1 1 2 3 8

The above table shows that 9 survivors were attended to during the reporting period with 56 % of survivors aged between 0- 17 years and while 44% were aged between 18-45 years of age. Of the reported survivors, 77% were reported in Turkana County while 23% were reported in Samburu. The reporting is still low, and could be as a result of fear and intimidation by the perpetrators and cultural gender based inequities. The project will continue to increased awareness creation at the community level andalso collaborate with other stakeholders and empower the community to address stereotype, limitations of GBV reporting and harmful gender norms that predispose individuals to GBV.

Medical legal linkage and outcomes of GBV survivors During reporting the period, the project supported in tracking medico legal outcomes on the cases reported at Maralal County referral hospital, police station director of public prosecution and judiciary. The objective of the follow up is ensure positive justice outcome and enhance medical legal linkage for the survivors. Below were some of the finding from the follow up;

Table 23: Medicolegal Linkage and outcomes Jan- April 2019 Maralal County Referral Hospital and Police Station Forms of Survivors No. No. No. No. No. No. of Comments on GBV cases Sex ( Male, access reported to issued presented sentenced acquitte reasons for acquittal reported Female or ed the police with P3 in the to jail d any other) medic forms Court of al Care law 1.Sexual F-1 1 1 1 1 - 1 1 -Both the accused and Violence( complainant are below Defilement) 18 years of age. 2.Physical M-9, F-5) 14 14 14 14 3 7 4-failure of witnesses to Violence( testify in court- Assaults, 3- Lack of enough Injuries) evidence

3) F-3 1 3 3 1 - 1 1-Decision by the Psychological prosecutor due to lack Violence ( of enough evidence. Verbal 2-.Prefered Alternative aggression and Dispute Resolution insults) Mechanism

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Promoting positive gender norms During the reporting period, the project working in partnership with Gender and Child Protection Technical Working Group, County Government of Turkana department of gender, social services and health participated in planning and Figure 59: International Day of the African Child in Turkana County commemoration of the Day of the International Day African Child on 16th June 2019 The objective of the celebration was to create awareness on child rights. Health care, improvement of education to African child and child protection inclusive. The theme of the year’s celebrations was “Humanitarian Action in Africa: Children’s Rights First.” Over 500 children were reached with awareness creation on children rights during the commemoration

Gender integration and SGBV sensitization in Samburu and Turkana During the period, the project supported sensitization of HCWs, CHVs, students, teachers, community members and management teams on Gender integration/SGBV and FP/RMNCAH in Samburu and Turkana Counties as shown below:

Table 24: Number sensitized on gender integration and SGBV per cadre Cadre M F Total HCWs 10 14 24 Community Health Workers 21 15 36 Binti Shujaa and Moran’s 6 5 11 Students and teachers 415 198 613 Adolescents and Youth 44 46 76 Health Facility and Community 90 69 159 Health Committees

The above figure indicates the number reached with sensitizations on Gender integration and SGBV prevention and response with an objective to create awareness on gender norms, how to address negative, sexual based violence prevention and response, FP/RMNCAH/ Nutrition and WASH

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Collaboration and partnership During the period, AFYA TIMIZA collaborated with Y –ACT to advocate and support the County government of Samburu department of gender to review the gender policy and develop road map for anti- beading policy under the leadership of the county director gender. The team agreed to support in development and advocacy of the gender and anti- beading policy which is expected to address gender based in equities and equalities and promote FP/RMNCAH/Nutrition and WASH services access and utilization. 36 (M-20, F-16) Figure 60: Deputy Governor Samburu County during gender participants in attendance. policy and Anti-beading policy The Project also participated in the dissemination of GBV data stakeholder’s forum collection and reporting platform which the County management is focusing to utilize to strengthen GBV data management. 15 (M-7, F-8) Participants were in attendance. Additionally, technical support was offered in review of the SGBV forensic evidence management module with an objective to enhance the module to offer a guide in management of forensic evidential materials in sexual offences which acts as the link between the health facilities and the criminal justice system. It is essential in helping the survivor of sexual violence access legal justice through the judicial process. 25 (M-11, F-114) Participants were in attendance from Health sector, Police, Gender Actors, Social services, Judiciary, legal sector, Office of Director of public prosecution and Government chemist

Lessons learnt: multi-sectorial approach enhances Gender integration and Sexual Gender Based Violence prevention and response in FP/RMNCAH

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III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT)

The attached Performance Data Table presents the basic data required to assess progress toward the achievement of the targets by AFYA TIMIZA. IV. CONSTRAINTS AND OPPORTUNITIES

During the period under review, the insecurity situation experienced in Turkana South continued to hinder health facility visit to provide technical assistance and access for health services. Besides, the ravaging drought stretched impacted negatively on the main source of livelihood for the nomadic population who entirely depend on the livestock. Other major challenge was that the project did not have obligated funds for a month in the quarter under review. As such, planned activities that required financial resources were frozen for a period of 31 days. Project technical staff were only able to implement cost neutral activities including collaborating with the MOH. Our collaboration with the county governments and other partners at county level was fruitful and will continue to be an area of focus for the project. We will continue with these collaborative actions and will leverage our efforts in a bid to ensure improved health outcomes for the communities.

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V. PERFORMANCE MONITORING

During the quarter, AFYA TIMIZA continued with activities aimed at ensuring that data generated at all service delivery points are of quality and the data is used for making informed decision. This majorly involved strengthening systems at all levels, county, Sub County and facility levels as discussed below.

Data Use Turkana County Through support from AFYA TIMIZA, Turkana County is making use of data use calendar to institutionalize data demand and information use. Informed decisions aid in targeted improvements across all health system building blocks. Facilities have institutionalized facility level data reviews with staff interarogating departmeal data, feedback given and suggestions from peers implemented. This has shown improvements in Figure 61: FP/RMNCAH scorecards reporting rates and demand for data for decision making. displayed

Table 25: Data use Calendar with respective mapped decision Turkana South Type of Indicator Target Target Trends Decisions report

PREGNANCY AND NEWBORN Annual Quarterly Jan-19 Feb- Mar- JAN - Proposed Actions 19 19 MAR 19 Total Deliveries 4604 384 254 251 241 746 1. Mapping of pregnant Deliveries with partographs 4604 384 201 196 201 598 mothers and follow up. correctly filled 2. Conduct maternity open days and in reaches. Still births 0 0 7 2 4 13 3. Procure birth cushions for hard to reach facilities Neonatal deaths 0 0 2 2 1 5 4. Mentor HCWs partographs and ensure all Adolescent (10-19yrs) 0 0 0 0 0 0

deliveries have a complete Maternal deaths partograph Maternal Deaths 0 0 0 0 0 0 5. Mentor/train HCWs on Maternal Deaths audited 0 0 0 0 KQMH/QI 6. OJT on Maternity Number of Infants receiving 4604 384 138 124 161 423 correct use of PNC PNC( within 2-3days) register Number of mothers 4604 384 98 165 193 456 receiving PNC( within 2- 3days) PNC

Besides the data use calendar, The SCHMTs have been capacity built to be able generate FP/RMNCAH scorecards in a timely manner for sharing and feedback for improvement Samburu County To ensure that facilities achieve their targets while still maintaining quality of services, an “adopt a facility” strategy was adopted in Samburu East, where SCHMT were assigned facilities to monitor. This was done with the aim of ensuring facilities get feedback on their performance as well as guidance on how to use their data for service improvement. Figure 62: CHEW and facility in-charge reviewing the dashboard at Ndonyo Wasin Disp Samburu East USAID/KENYA AFYA TIMIZA PROGRESS REPORT FOR Q3 FY 2019 73

Data Quality Turkana County Targeted onsite data verification was jointly conducted by SCHMT and project staff to flush out inconsistencies between the various sources of data and what is eventually reported in KHIS. This has tremendously improved data quality aspects since there is improved concordance of data from the various sources. AFYA TIMIZA has supported the sub county teams to strengthen Data Quality Improvement (DQI) teams to lead in improving the quality of data. This has seen improvement in correct use of partograph through mentorship on use of the same in monitoring and the labor process, timely auditing of maternal and newborn death. Facility staff have also been supported to put up information Figure 63: Nurse at Nakabosan dispensary validating data on teenage corners to display the various pregnancies with A&Y officer from Afya Timiza during data review meeting trends, this helps in catching any anomaly in good time. Samburu County During the quarter, AFYA TIMIZA concentrated their efforts in ensuring improvements made during previous quarters were sustained. Through technical assistance, the project supported various activities including; facility data reviews, CMEs, data verification and documentation review as well as follow up of RDQA action plans in 32 facilities. In the subsequent quarter, the project will continue to support HRIOs to ensure data concordance and proper documentation is done.

Gap identified Description of action point Implementation status Data discrepancies especially immunization data Harmonize outreach and facility data 9/13 (69%) Monthly facility data review conduct monthly data reviews and verifications before sending reports to 20/28 (72%) not happening consistently SCHRIO Data analysis for decision Display data analysis in the facility and use it to inform decisions 17/19 (89%) making not done Registers not complete Complete registers by filling all the columns and doing page summaries 18/32 (56%) Poor documentation of Clean up OTP and SFP registers and use other admission criteria. 17/26 (65%) nutrition services Outdated partographs and Acquire new and updated registers as well as partographs 9/9 (100%) immuniztion register

Lack of PNC documentation Since the services were offered, reconstruct data and ensure contonuous documentation is done 5/9 (56%)

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VI. PROGRESS ON GENDER STRATEGY

During the quarter, the project supported sensitization of 159 Facility management teams and Community Units Committees in Turkana County on gender mainstreaming and integration with an aim to equip them with knowledge to enhance gender sensitive approach to leadership, governance and management. Moreover, 26 HCWs were trained on gender integration and SGBV prevention and response to build their capacity on gender sensitive normative care and Post GBV Care in FP/RMCAH service access and utilization. AFYA TIMIZA offered technical support on development of ant-beading policy. The policy aims to offer a framework to address harmful practices of beading and negative outcomes among girls in Samburu County. Working with other gender actors and under the leadership of CEC – Gender and Social services department in Samburu County, the project offer technical support in review of the gender policy. The project supported commemoration of international day of the African Child in Turkana with an aim to advocate and create awareness on children’s right. Additionally, the project support department of gender and health in Samburu to celebrate the menstrual day hygiene and distribution of sanitary towels to promote dignity of girl child and Sexual Reproductive Health Rights. Project continue to appreciate the role men play in decision makers in Samburu and Turkana County communities therefore worked closely with the community members and existing community structure i.e. Kraal leaders, Samburu council of Elders and Emurons to advocate and lobby support for utilization FP/RMNCAH/Nutrition and WASH services to promote gender equality and enhance health services access. Gender integration was enhanced multi-sectorial collaboration and partnership as part of for gender transformative approach for improved FP/RMNCAH/Nutrition and WASH. VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

Table 26: Environmental Threats and Mitigation Measures by the Project during the Quarter Environmental threats by AFYA TIMIZA Mitigation measures activities

Improper disposal of training materials such as • Sensitization and education of community Condoms and waste paper used during trainings members and trainees on associated risks and appropriate disposal methods • The project using Amref policy on waste paper disposal for papers used during trainings and questionnaires and tools used for data collection Improper storage of commodities (FP commodities, • Sub-county pharmacists, HRIOS and nutritionists contraceptives, condoms & nutrition supplements); were trained on in quantification, forecasting and general commodity management. to ensure that facilities are adequately stocked and prevent understocking and wastage of commodities through expiry Medical waste disposed indiscriminately thus posing • Facilitate and support Sub County & County potential for transmitting diseases and not health management teams to ensure safe disposal incinerated as per set standards of hazardous waste • Provide Safety containers/color coded bins for storing various categories of medical wastes including sharps.

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VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

• The project also continued strengthening the availability of commodities by collaborating closely with AFYA UGAVI to monitor stock outs as well as sensitize health care workers on commodity management • In order to identify and categorize nutrition status of children under the age of 5 years, Afya Timiza in collaboration with NHP plus, supported growth monitoring and promotion exercise at CHUs and ECD centers in both Samburu East and Central. • The project also worked with PACE on issues of budget advocacy in Samburu county as well as CMLAP II on monitoring and strengthening data use at county level. IX. PROGRESS ON LINKS WITH GOK AGENCIES

• In Turkana County, Afya Timiza continued to spearhead the development of a health financing strategy and engaging in discussions to develop a UHC framework and road map that suits the unique needs of the agro-pastoral residents • During the reporting period, the project offered technical support County to departments of health and gender in Samburu County in planning and commemoration of Menstrual Hygiene Day with an objective to promote gender equitable reproductive health services among adolescents and youth. • To address financial barriers to access as well as catastrophic expenditure on health for communities in hard-to-reach areas, Afya Timiza continued to engage and facilitate NHIF officers in Samburu County to sensitize communities on the need for health insurance and also accredit health facilities.

X. JOURNEY TO SELF RELIANCE (J2SR)

USAID defines self-reliance as the a capacity to plan, finance, and implement solutions to local development challenges and a commitment to see these by ensuring the right laws, policies and actions are in place.

Through this lens, AFYA TIMIZA has had the following milestones 1) Identifying health system gaps in Leadership, Management and Governance; Health Financing; Health Workforce; Health Information Systems; Medical Products; Health Service Delivery; Health System Accountability; 2) Building the capacity of key decision makers/actors at all levels of the health system from County, sub-county, health facility and community including the legislative arm of the county government; and 3) Collaborating, Learning, and Adapting (CLA) approach to target bottlenecks affecting management, system quality and community engagement. To remain on the self-reliance path, the project continued to work with the county department of health, county assembly health committee and other structures to promote commitment in county health leadership, management and governance. As such, 28 health facility management committees (HFMCs) in Turkana County were trained on corporate governance and understanding the budgeting and planning process and 26 facility in-charges in Loima, Kibish and Turkana South Sub-Counties underwent similar training to build on their knowledge and skills for effective leadership management and governance of resources and enhanced service delivery within level two and three facilities. We continued to spearhead the development of a health financing strategy and engaging in discussions to develop a UHC

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framework and road map that suits the unique needs of the agro-pastoral residents in Turkana. The project will continue these engagements at all levels to ensure there is a supportive environment, the people are involved in planning and holding county governments accountable, and identified capacity gaps in planning, budgeting and implementing service delivery are addressed. XI. SUSTAINABILITY AND EXIT STRATEGY

The AFYA TIMIZA sustainability plan is conceived on the premise that county entities (community, public and/ or private) will progressively assume responsibility for FP/RMNCAH, Nutrition and WASH programs and outcomes. The plan focuses on the four dimensions of county ownership and stewardship, institutional and community ownership, capabilities, and mutual accountability including financing.

County ownership and stewardship: To ensure county ownership and leadership, the project worked under the leadership of the county and in partnership with other stakeholders from the public and private sectors and civil society to determine gaps and challenges, and solutions needed to achieve the desired outcomes. This was through structured mechanisms that included: breakfast meetings with CHMT and county leadership, Project Steering Committee meetings and, Technical Working Groups.

Institutional and community ownership: The project empowered and partnered with the communities to ensure ownership and understanding of their roles and responsibilities in bridging the gap between them and the formal health system, while addressing socio-cultural barriers to adoption of desirable FP/RMNCAH practices. This was through strengthening of community health systems and linking them to the health facilities.

Capabilities: The project developed the capability of the county and sub-county leadership in knowledge and technical skills, leadership and governance, coordination and stakeholder engagement. This was through training, mentorship and on-job trainings.

Mutual accountability including financing: The project supported the project in APRP, program based budgeting, monitoring and evaluation and use of dashboards for accountability of results.

XII. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE)

N/A

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XIII. SUBSEQUENT QUARTER’S WORK PLAN

Planned Actions Actual Status Explanations for from Previous Quarter this Quarter Deviations Integrated family planning, reproductive, maternal, Done No deviation child and adolescent health (FP/RMNCAH), nutrition; water, hygiene and sanitation (WASH) quarterly support supervision Conduct trainings to Health Community Workers Not done To be conducted in the next quarter (HCW’s) on Emergency Obstetric and Newborn Care (EmONC) Train HCWs on respectful maternity care Not done To be conducted in the next quarter Training of sexual gender based violence (SGBV) and Done No deviation Gender Integration trainers of trainers (TOTs) Train selected CHVs to provide injectable FP at the Not done To be conducted in the next quarter community level Conduct trainings to HCWs on IMCI Not done To be conducted in the next quarter Conduct trainings to HCWs on EPI Not done To be conducted in the next quarter Basic counselling skills for Health Workers Not done To be conducted in the next quarter Train HCWs on Long Acting Reversible Not done To be conducted in the next quarter Contraceptives

XIV. FINANCIAL INFORMATION

The total estimated amount for the award is US$ 24,500,000 while the total obligated amount was increased from 13,193,495 to $17,429,493 via modification #5. During the quarter, we spent a total of US$ 1,361,807, bringing the cumulative expenditure as at the end of June 2019 to US$ 13,761,299, representing a 79% burn rate against the obligated amount, and 56% against the total estimated budget. Total cost share for the quarter amounted to US$ 62,796, resulting to a cumulative cost share of US$ 1,491,728 against a total cost share budget of US$ 1,582,545. Amref continued to receive monthly advances from USAID during the quarter. Financial reports (SF 1034 vouchers) were submitted monthly to the AOR to liquidate the advances received. As of June 30, 2019, a cumulative total of US$ 13,193,495 had been received from USAID, leaving us with cash deficit of US$ 567,804 owing from USAID. This reimbursement is expected by the end of July 2019.

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Cash Flow Report and Financial Projections (Pipeline Burn-Rate) CHART 1: OBLIGATIONS VS. CURRENT AND PROJECTED EXPENDITURES

Pipeline 20,000,000

18,000,000

16,000,000

1,528,186 14,000,000 1,361,807 12,000,000 1,733,184

10,000,000 2,126,278 17,429,493 8,000,000

6,000,000

4,000,000 8,540,031

2,000,000

- Obligation Expenditure Pipeline

YR 1&2 Actual Q1 Actual Q2 Actual Q3 Forecast Q4 Forecast

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BUDGET DETAILS T.E.C.: $24,500,000 Cum Oblig: $17,429,493 Cum Expenditure: $13,761,299

Oct-Dec 2018 Jan-Mar 2019 Apr-Jun 2019 Jul-Sep 2019 Obligation Q1 Actual Q2 Actual Q3 Actual Q4 Forecast Expenditures Expenditures Expenditures Expenditures Total: 13,193,494.97 2,126,278 1,733,184 1,361,807 1,528,186 Personnel 422,520 441,711 456,335 455,749 Fringe Benefits 89,260 93,918 95,941 99,722 Travel 13,461 5,873 6,516 10,500 Equipment - - - - Supplies 16,857 12,538 2,462 12,000 Contractual 397,723 206,894 200,306 256,454 Construction 4,149 6,743 - - Other Direct Costs 816,193 420,820 365,765 430,629 Indirect Costs 366,114 544,687 234,483 263,131

BUDGET NOTES

Salaries increased in Q2 following an organization-wide cost of living Personnel increment of 5% effected in January 2019. This increment had been factored in the approved budget Staff Fringe costs increased in Q2 following an organization-wide cost of Fringe Benefits living increment of 5% effected in January 2019. Travel is expected to increase slightly in Q4 as we accelerate Travel performance towards the end of the year

Equipment No equipment is budgeted for during the year Supplies are anticipated to increase in Q4 as we procure more supplies Supplies for the remaining trainings for this year Sub award costs are expected to increase marginally in Q4 as the Sub Contractual recipients accelerate performance towards the end of the year

Renovations for Health Facility maternal shelters have been completed Construction This category is expected to increase marginally in Q4 as we accelerate Other Direct Costs performance towards the end of the year This is based on Amref’s provisional NICRA of 20.8% and is a function of Indirect Costs the total direct costs.

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SUB-AWARD DETAILS Total Amount in the approved budget for sub-awards: $4,017,326 Total Amount sub-awarded to date: $2,908,374

Sub Recipient Total Sub Award amount (US$) Center for Behavior Change & Communications – CBCC 1,262,483 Communities Health Africa Trust – CHAT 525,826 Inter-Religious Council of Kenya – IRCK 478,293 Options Consultancy Services (UK) Ltd* 641,772 Total 2,908,374 *Options UK exited the program in August 2017.

XV. ACTIVITY ADMINISTRATION

Personnel

There were no changes to the project staffing in the quarter under review.

CONTRACT, AWARD OR COOPERATIVE AGREEMENT MODIFICATIONS AND AMENDMENTS During the reporting period, we received the 5th agreement modification. This modification increased the obligated funding by US$ 4,235,998.03 thereby increasing the obligated amount from US$ 13,193,494.97 to US$ 17,429,493. The modification also incorporated the following standard provisions to the agreement: M11 - Recipient and Employee Conduct (June 2018), M24 - Prohibition on requiring certain internal confidentiality agreements or statements (May 2017), M27 - Nondiscrimination against beneficiaries (November 2016), M28 - Conflict of interest (August 2018) and RAA2 - Protecting Life in Global Health Assistance (May 2019). XVI. INFORMATION FOR ANNUAL REPORTS ONLY

N/A

XVII. GPS INFORMATION

See attached GPS Annex 111 on GPS information

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XVIII. SUCCESS STORY GUIDELINES

Giving Babies in Samburu a Chance to Survive and Thrive

“………..when you come to the hospital and the complications. Fortunately, with the support of doctors tell you that you have to give birth five USAID through Afya Timiza, the neonatal unit weeks before the date they had indicated, you have was renovated. The Afya Timiza team also to think twice.” introduced the Kangaroo Mother Care Unit. The quality of neonatal services in this hospital Elizabeth Lengur, 25, was attending her routine has greatly improved as we are able to cater antenatal clinic for the second time, three for all degrees of premature and low birth months past her scheduled visit. The nurse weight babies that are delivered here,” explains informed her that they needed to deliver the Makena. baby immediately or both mother and child would lose their lives. Elizabeth later found out A Life Saving Cuddle: that the persistent headaches she had been suffering had been a sign of danger. She had Elizabeth is one of the beneficiaries of the developed pre – eclampsia. newly renovated neonatal unit at Samburu County Referral Hospital. “With every passing “During my first pregnancy I delivered a day, my baby’s appetite continues to increase; healthy baby boy at 38 weeks just as the doctor her weight has increased from 1,650 grams to had written in the maternity book, same as 2,100 grams in eight days. The nurses say it is most of the mothers I know. But when you because of the skin-to-skin contact with the come to the hospital for your second delivery baby using the kangaroo mother care and the doctors tell you that you have to give approach,” Elizabeth explains. birth five weeks before the date they had indicated, you have to think twice,” Elizabeth explains.

After counselling from the midwife, Elizabeth learnt that there are ways to stabilize and monitor a baby to maturity with the support of nurses at the hospital, something Elizabeth had never heard of. She accepted the doctor’s advice to help her induce labour urgently.

The Neonatal Unit

According to Lucy Makena, the nurse in charge of the maternity wing at Samburu County Referral Hospital, there has been a 40% increase in the uptake of maternal and new- born services in the last two years. However, Elizabeth Lengur, practicing Kangaroo Mother incidences of babies born prematurely and Care for her pre term baby. Picture by Edna Mosiara – Afya Timiza. underweight like Elizabeth’s case are also on “Through the combined efforts of partners like the rise. The hospital had a challenge supporting premature and underweight babies Afya Timiza and the Samburu County due to the lack of a fully equipped and Government, community health workers are established neonatal unit. To avoid incidences trained to sensitise mothers in the community of infection, mothers and their babies were on attending antenatal clinic and observing referred to Nakuru County Referral Hospital pregnancy danger signs, although not all which is six hours away by road. mothers adhere to the routine check-ups as required. However, the number of mothers “Stabilising premature babies while on transit, opting skilled delivery has increased and the especially those born before 32 weeks, was County government is constructing a new difficult and some babies would develop

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maternity wing to accommodate them,” Lucy neonatal unit in Samburu County, and two explains. maternal shelters in Turkana County.

Since its renovation, the neonatal unit has successfully supported 171 babies with 72 being pre term. To improve the quality of maternal and new-born services, USAID through Afya Timiza has supported the renovation of two maternity units and one

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Samburu Muslim Women Embrace Cervical Cancer Screening

“Despite the lack of knowledge, fears and To increase access to health services by the misperceptions relating to medical examination, Muslim community, the Afya Timiza team discomfort with male health workers and limited conducted an outreach including cervical spousal approval; community awareness on cancer screening at Jamia Mosque in Maralal – reproductive, maternal, new-born, child and the first time for the project to offer services adolescent health through sensitisations done by at the Mosque. Sheikhs and Imams is saving the lives of Muslim women in Samburu County.” Sheikh Ahmed After sensitization on cervical screening during Medo, Chairman of the Samburu Supreme the outreach, eight women agreed to be Muslim Council of Kenya. screened and seven were negative while one who presented suspicious symptoms was Cancer is the third leading cause of death in referred to Maralal County Referral Hospital Kenya after infectious and cardiovascular for further tests. diseases. In 2018, the annual incidence of cancer was estimated at 47,887 new cases, “I knew there was a disease called cancer but with an annual mortality of 32,987. Cervical nothing else. I have now only learnt of the different cancer was ranked the second leading cause of types of cancers including cervical cancer through cancer deaths at 10% (3,266 deaths) the Afya Timiza trainings,” said Foziah Juma, now (GLOBOCAN, 2018). a trained religious TOT. The health status of the people of Samburu To build on what exists, enhance progress and County is influenced by environmental and improve uptake of health services not limited socio-cultural factors, practices and beliefs, to cervical cancer screening among the low literacy levels and high fertility rates as congregational and community members, Afya presented in the Kenya Demographic and Timiza will continue integrating the provision Health Survey (KDHS 2014). According to of organized health services at religious Samburu County’s Annual Work Plan 2019- platforms not limited to churches and 2020, the estimated population of women of mosques. reproductive age in Samburu East and Samburu Central is 46,939, but only 189 women have undergone cervical cancer screening. So far, Afya Timiza has trained 150 religious leaders from various denominations in Samburu and Turkana Counties. With funding from USAID through Afya Timiza, the capacity of religious leaders has been built to sensitize congregations on Anthony Lotukoi, reproductive, maternal, new-born, child and Project Officer adolescent health as well as nutrition and sensitizing mothers on hygiene with the aim of improving the uptake cervical cancer of these services. Islamic women have also screening during an been beneficiaries of the messages outreach. Picture by disseminated by the trained Sheikhs, Imams Sarah Kimani – Afya and youth trainers of trainers (TOTs). Timiza

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The Testimony of a Community Health Worker:

Cecilia Apaa - Community Health Worker; Samburu County

“I have worked as a CHW for 7 years now. The effectiveness of a CHW is largely determined by their ability to provide preventative, promotional and rehabilitative care to communities. For low literacy communities this is not an easy feat without the support user friendly tools.

Recently we have been trained on how to supplement health messaging with visual aids and audio devices like illustration guide books and digital radios -digisomo - . These have made my work more exciting and rewarding.

Looking at how patriarchal barriers have been customary to the women in pastoral communities, it became urgent that we engage men as the key decision makers in families to improve the socio cultural and gender norms.

We started engaging fathers to empower them on how to establish a saving plan for their unborn baby and to ensure that they support their spouses to attend at least four antenatal care visits before delivery.

Fathers who are members of father support groups say they have learnt how to negotiate better with their spouses. Mothers say that their spouses accompany them to the health facility for ante natal checkups and provide for transport to the health facility when delivery time comes”

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ANNEXES & ATTACHMENTS

ANNEX I - AFYA TIMIZA PERFORMANCE DATA TABLE

ANNEX II - AFYA TIMIZA SF 425 FEDERAL FINANCIAL REPORT

ANNE III - GPS Information

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